Elevance Health-Affiliated Plans Streamline Prior Authorization to Reduce Administrative Burden for Care Providers While Protecting Patient Safety and Controlling Costs for All
Prior authorization helps to determine whether a health plan covers certain non-emergency tests, procedures, prescriptions, supplies, or services. For decades, it has helped ensure people receive the right care, safely, at the right time, and in the right setting.
Employers, individuals, and government entities hire health plans like ours to manage the administrative work of health insurance and related services. Reviewing medical procedures, services, and medications for appropriate use through prior authorization is a fundamental piece of that work. We continually seek ways to streamline prior authorization’s administrative steps while preserving the ability to protect patient safety and help keep healthcare costs under control.
Enhancing Patient Safety and Minimizing Delays
Prior authorization helps protect patient safety by confirming patients receive care and medications that are based in scientific evidence. When a health plan member receives care from multiple providers, prior authorization helps make sure that care is coordinated, safe and effective. It double-checks a proposed treatment for medical and medication errors as well as use of unproven care. It catches prescriptions for devices or medications that are not approved by the United States Food and Drug Administration, and monitors medications that have a high potential for misuse. These steps – from helping to avoid negative medication interactions to ensuring that certain medical treatments take place before jumping ahead to surgery – put safeguards in place and use data from hundreds of thousands of similar procedures and prescriptions to assure best practices.
Care providers know their individual patients best. We serve people across their entire health journey and are privileged to have access to the collective health outcomes of nearly 50 million patients. True partnership happens when we share our knowledge and work together to achieve optimal health outcomes.”
President, Carelon Health
Elevance Health also works to make prior authorization happen faster. Most prior authorization requests are submitted by care providers to health plans via phone, mail, or fax, which adds considerable processing time. As outlined below, our company has invested in digital solutions that enable and encourage care providers to use real-time prior authorization submission and workflow services.
In our continuous effort to accelerate prior authorization reviews, we are harnessing the power of artificial intelligence tools to speed up approvals. Denials are reviewed and determined by clinicians, and in a majority of cases, they are professionals with the same specialty as the treating physician. This helps to enable the prompt scheduling of needed services and decrease confusion and frustration. Across Elevance Health’s affiliated plans, approximately 70 percent of prior authorization requests handled by Carelon Medical Benefits Management are approved instantly, and approximately 95 percent are approved in less than 24 hours; it’s important to note that urgent care is always available immediately.
Partnerships with Healthcare Providers Reduce or Eliminate the Need for Prior Authorization
We continually seek ways to improve our partnerships with care providers. Working together, we have developed a technology-enabled, multidimensional approach that reduces the need for prior authorization requirements and provides streamlined information to clinical reviewers to make their reviews more efficient, while maintaining patient safety and controlling costs.
Elevance Health helps care providers adopt innovative secure data exchange platforms that make it possible for the payer and care provider to securely exchange real-time information about a patient’s conditions. Not only does this partnership help patients get timely care, but it also cuts down on the administrative cost and burden for both care providers and health plans. Elevance Health care provider partners have commended the efficiency and quickness of processing prior authorizations, and we continue to onboard more care providers in this program.
For certain large high-performing care providers, the Elevance Health Prior Authorization Pass (PA Pass) program (similar to commonly known “gold card” programs exempting providers from prior authorization requirements), waives approximately 400 outpatient procedure codes such as those for mastectomy, breast reconstruction, rotator cuff surgery, bunion surgery, knee arthroscopy, surgeries to remove tonsils or adenoids, and laparoscopic gallbladder surgery. Care providers qualify for the program when they are in value-based payment agreements with Elevance Health-affiliated plans and meet specific performance criteria. Currently, 17 health systems in six states representing more than 60,000 physicians qualify for PA Pass. For example, Cleveland Clinic has been enrolled in Elevance Health’s PA Pass program since 2018.
For smaller groups of care providers, the Prior Authorization Optimization (PAO) program allows automatic and immediate clearance upon electronic authorization for approximately 250 outpatient procedure codes such as sinus surgery, surgeries to remove tonsils or adenoids, laparoscopic hernia repair, laparoscopic gallbladder removal, hysterectomy, and carpal tunnel surgery.
Providers that use electronic systems also benefit from two-way communication with clinicians at Elevance Health-affiliated plans, as well as cleaner and more complete authorization information leading to quicker clinical determinations. And care providers can access all authorization data in a single location and quickly check the status of any authorization, even if it was not initially submitted electronically.
Where prior authorization is needed, digital technologies have made it significantly faster and more efficient. One study found care providers save an average of 11 minutes for each request when using electronic prior authorization; this translates to providers having more time to spend with their patients. The study also estimated that by just conducting prior authorization via electronic clinical records, the healthcare industry could potentially save $449 million per year because of reduced administrative cost and burden. It’s important to highlight that these savings are administrative, as Elevance Health-affiliated plans do not use costs as a factor when making prior authorization determinations.
A Future Focused on Quality, Accessible, and Affordable Care
We’re working with industry stakeholders to advocate for the development and wider adoption of electronic prior authorization (ePA). Elevance Health has participated in Health Level Seven (HL7) International since 2018, taking part in the development of new Fast Healthcare Interoperability Resources (FHIR) data standards for ePA, FHIR “Connectathons,” and the United States Realm Steering Committee, the Attachments Work Group, and the Payers/Providers Work Group. One of these efforts, HL7’s The DaVinci Project, was highlighted in a presentation by the Centers for Medicare and Medicaid Services (CMS) to the Office of the National Coordinator of Health Information Technology (ONC) as a tool to help reduce physician burden.
Even as it evolves, prior authorization remains an essential tool for promoting high-quality care. By continuously reevaluating and improving upon traditional models of care, Elevance Health leads the way in promoting a health system that is more responsive to the needs of patients and care providers. Our focus on modernizing prior authorization, embracing digital solutions, and investing in improved automation that seamlessly integrates into electronic health records represents a commitment toward creating a patient-centered healthcare experience that is safer, more efficient, and accessible.
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