2023 changes to prior authorizations: Here’s what it means for benefits
Many states and health plans are currently implementing new legislation, so it’s more important than ever for self-insured employers and benefits advisors to be on their toes – swift and significant changes are afoot.
Texas’ physician “gold card” rules took effect in October of 2022. According to this law, physicians are exempt from prior authorization requirements for specific services if they have a six-month prior authorization approval record of 90% or higher.
Just recently, Pennsylvania state lawmakers passed a bill aimed at streamlining the prior authorization process. Now an act that has been signed into law, it requires more timely approvals from insurers, as well as a peer review process for complex cases. It would also necessitate an electronic portal where all prior authorizations and supporting documents are aggregated into a central site.
These are just two examples of legislation that states and health plans are implementing as we move into 2023. It’s more important than ever for self-insured employers and benefits advisors to be on their toes – swift and significant changes are afoot.
Recognizing the need for change
Rep. Aaron Bernstine, who originally introduced the Pennsylvania bill, did so because he, like many, recognized the inefficiencies in the prior authorization process that have caused increased costs for providers, their patients, and policyholders. In addition to the lack of transparency, accessibility, and consistency of prior authorization submission, he acknowledged that many things contribute to setbacks in the delivery of quality health care to people everywhere: lack of standardization of paperwork; restrictions; amendments; and lack of electronic submission capabilities. Jointly, all these hurdles create a poor experience for both patients and providers.
One of the most time-consuming and laborious aspects of administrative work for both providers and payers is prior authorizations, largely because many processes for doing this are still dependent upon manual exchange of information, such as faxes, and there is next to no automation of workflows across the industry. This can make it challenging to determine when exactly authorization is required. Plus, these can be moving targets, which means providers and payers are each monitoring how to manage and integrate complex technologies.
When it comes to prior authorization, delays can disrupt the entire healthcare ecosystem, which can ultimately delay patient care. A recent survey by the American Medical Association showed that these delays were often cited as reasons patients abandon treatment or experience negative clinical outcomes. Furthermore, 34% of physicians report that delayed prior authorization has led to a serious adverse event for a patient they were caring for.
New prior authorization legislation identifies and highlights the need for reform in the prior authorization process to mitigate these issues. It requires health care providers and insurers to adhere to standards and timely feedback for prior authorization for all medical treatment and procedures, with application to commercial health insurance carriers and Medicaid plans. The main goal is to expedite health care treatment delivery so that outcomes are improved, and relationships between health care providers and their patients are enhanced.
When patients are connected to proper treatment earlier, they are in a position to take a more proactive approach. It will keep more patients out of the emergency room and reduce health care costs overall – including for employers.
Finding the perfect solution
Fortunately, there are emerging tech solutions designed to relieve the burden of prior authorization ahead of these changes. With increasing legislation, now is the time for benefits advisors, providers and payers to prepare for new compliance requirements.
Implementing electronic workflows through modern payer and provider collaboration technologies is a necessary game-changer. The growing complexities of medical regulations, guidelines, and standards are burdensome for all involved. Automation allows providers and their staff to easily retrieve information from patient charts and prepopulate forms, speeding up the process and supporting more rapid patient care.
When modern payer and provider collaboration tools are used, automatic requests can be made for the exchange of financial, clinical, and administrative data in real-time, allowing providers to have access to the most up-to-date information regarding approvals, denials, and medical review status. Ultimately, cloud-based solutions simplify the prior authorization process without demanding significant changes to provider behavior and payer workflow processes, facilitating the development of trust between payers and providers and maximizing patient care.
When there is electronic collaboration from beginning to end between payers and providers, everyone has access to current, user-friendly, and intuitive integrated data resources – and this is true across the health care spectrum. When communication flows freely and ambiguity is eliminated, it results in increased efficiency and precision for the patient. Patients with a superior health care experience are more likely to take a proactive approach to their health, which results in better health outcomes and fewer medical setbacks. In turn, employers’ expenditures are reduced through better, faster care.
Regulatory changes in prior authorizations require the full power of technology to enable rapid payer-provider collaboration. Health care payers are beginning to shift their prior authorizations from a laborious manual process to a streamlined automated data exchange, ultimately revolutionizing prior authorizations and leading to faster, more precise care.
Christina Perkins has been finding ways to leverage technology to address business process challenges in health care for over 20 years. As a product and business leader at NantHealth her focus is on solutions that streamline interactions and information exchange between health care payers and providers, supporting the growing adoption of value-based care and contracting and overall operational efficiency.