KLAS Points of Light: Streamlining Prior Auths with FHIR API

The healthcare industry is continually evolving, with technology playing a crucial role in enhancing efficiency and patient care. One of the significant pain points in healthcare administration has been the cumbersome prior authorization process.

A collaborative initiative by Humana, athenahealth, and Availity has demonstrated how innovative solutions can streamline this process using Fast Healthcare Interoperability Resources (FHIR) APIs. This case study earned a KLAS Points of Light Award in 2024.

The Challenge of Prior Authorizations

Prior authorizations are vital for ensuring that patients receive appropriate and cost-effective care. However, the traditional process is fraught with manual interventions, analog technologies, and inconsistent standardization. Providers often face significant delays and administrative burdens due to varying payer requirements and data management challenges. The necessity to manually verify demographic and clinical data adds to the inefficiency, making the process time-consuming and error-prone.

A Collaborative Solution

To tackle these issues, Humana, athenahealth, and Availity embarked on a project to develop an automated end-to-end prior authorization process. This initiative leveraged the Da Vinci Burden Reduction Implementation Guides, which include Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR), and Prior Authorization Support (PAS). These guides facilitate an integrated workflow that enables the automated submission of prior authorizations directly from Electronic Health Record (EHR) systems.

The collaboration involved meticulous analysis of the implementation guides and the internal systems of each participating organization. The teams worked closely to clarify implementation details, ensuring a smooth integration. This joint effort exemplified the power of collaboration in the healthcare sector.

The Implementation Process

The implementation process can be broken down into three key steps:

1. Coverage Requirements Discovery (CRD):
   • The EHR system uses the payer’s FHIR-based CRD API to determine if authorization is necessary for the requested service.
   • The payer responds with a ‘yes’ or ‘no.’ If ‘yes,’ additional information regarding the necessary documentation is provided.
   • This step enhances coordination and efficiency by providing real-time authorization requirements.
2. Documentation Templates and Rules (DTR):
   • If prior authorization is needed, the payer’s system may request the completion of a questionnaire or additional clinical information.
   • This automation reduces the need for manual data entry and ensures that all required details are included upfront, minimizing delays.
3. Prior Authorization Support (PAS):
   • The EHR sends the authorization request and medical documents as a FHIR bundle to the health information network.
   • The network translates this transaction and forwards it to the health plan using the existing X12 278 process.
   • The health plan processes the request and responds with an authorization reference number and status, which is communicated back to the EHR in real time.

Project Goals and Outcomes

The primary goals of this initiative were to improve transparency, reduce administrative burdens, leverage available clinical content, and increase automation opportunities. The results were impressive:

• Burden Reduction: The integration saved provider staff approximately 4,396 hours per month that would have been spent on authorization verification. This was due to 17,585 orders requiring no authorization.
• Touchless Resolution: Nearly 54% of all requests per month required no authorization, and 70% of authorizations were auto-approved, significantly reducing manual intervention.
• Fast Resolution: The average time for authorization approval or denial was 26 hours, far exceeding the industry average of days to weeks and the CMS target of seven days.

Lessons Learned

Several key lessons emerged from this project:

• Understand EHR Workflows: It is crucial to understand provider workflows to implement functionalities that create the most significant impact.
• Set Clear SLAs and Metrics: Agreeing on Service Level Agreements (SLAs) and key metrics early on enables effective reporting and analysis.
• Align on Success Criteria: Consistent definitions of success versus failure are essential for coherent project evaluation.
• Continuous Review and Feedback: Regular reviews of implementation guides and feedback through initiatives like the HL7 Da Vinci project are vital for continuous improvement.
• Unique Identifiers: Utilizing unique identifiers across all steps helps in associating various elements of the authorization process, ensuring clarity and traceability.
• Data Availability: Addressing gaps in data availability within EHR systems is necessary to meet payer requirements.

Conclusion

The collaborative effort by Humana, athenahealth, and Availity showcases a successful model of leveraging technology to overcome administrative challenges in healthcare. By automating the prior authorization process through FHIR APIs, they have significantly reduced administrative burdens, enhanced transparency, and expedited patient care. This case study not only highlights the potential of technology in healthcare but also serves as a guide for other organizations looking to streamline their operations.