Health insurers need to restart care management: AHIP
The insurer group says precertification and preauthorization programs can improve the quality of care.
Doctors and hospitals love to hate health insurers’ efforts to manage care, but the board of America’s Health Insurance Plans (AHIP) says carriers should start to reactivate care management programs.
Many health insurers suspended some or all active care management programs as health care providers were mobilizing to fight the COVID-19 pandemic. Some let up on care management as part of their own emergency planning, in compliance with state mandates, or through responses to state emergency planners’ requests.
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Now, bringing those care management programs back online will be a part of safely re-opening the U.S. health care system, the AHIP board said in a statement.
Health insurers often use procedures such as precertification and preauthorization to manage enrollees’ use of health coverage, by deciding ahead of time whether proposed procedures are appropriate for a patient, and whether the patient’s plan will cover the procedures.
Health insurers waived preapproval requirements, and other administrative requirements, in March, to ease burdens on health care providers.
Some health care providers are still struggling with a surge in patients with severe cases of COVID-19, and health insurers want to continue to help those providers cope with capacity challenges, the AHIP board says.
As health care providers in less hard-hit areas get back to normal, health insurers will bring back preauthorization and precertification programs for those providers, the AHIP board says.
“Used in a targeted manner, these tools have been effective in improving quality; protecting patient safety; promoting case management for high-risk members; and preserving valuable resources by detecting fraud, waste, and abuse,” the AHIP board says. “Achieving these goals will become even more critical as the nation continues to work to mitigate risks from COVID-19.”
Health insurers want to help patients get care, but they also want to make that the care provided is efficient, and is supported by medical evidence, the AHIP board says.
The AHIP board says it believes health insurers should streamline preapproval processes as much as possible, both to ease burdens on providers, and to reduce patients’ risk of contracting COVID-19 while getting routine and elective care, by helping patients get care as quickly as possible.
Health insurers should streamline preapproval processes through automation, electronic information exchange, programs that identify high-performing clinicians, and value-based provider contracts that discourage use of unnecessary medical tests, treatments and procedures, the AHIP board says.
The AHIP board also has ideas about how health insurers should handle preapprovals given before March 13, when the COVID-19 emergency blocked patient access to routine and elective procedures.
Health insurers should try to refresh those preapprovals, to eliminate the need for patients and providers to re-apply for preapprovals, the AHIP board says.
AHIP is encouraging insurers to make the preapproval grace periods last for at least 90 days, or until local backlogs for routine and elective care are cleared.
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