Prior Authorizations as a Use Case for Solving Interoperability

In the wake of the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule, there’s a heightened focus for health plans to streamline the prior authorization review process and deliver more timely decisions at the point of care. During a recent presentation at ViVE, I highlighted the potential of utilizing artificial intelligence (AI) and a multi-payer portal to solve two of the biggest industry challenges in healthcare right now: the proliferation of single point solutions for prior authorizations and the push for industry standards. To watch the full presentation, please click here.

This blog outlines the three strategic principles I covered in my presentation. These principles are designed to assist health plans in achieving not only regulatory compliance with the CMS Interoperability and Prior Authorization Final Rule but also align disparate systems across the industry. Utilizing standardized APIs via a centralized multi-player portal powered by AI enhances prior authorization reviews and serves as a gateway to accessing clinical data for broader improvements in the care delivery process. Once clinical data is acquired it can be leveraged to optimize other essential workflows, such as care management and treatment coordination.

Principle #1: Prior authorizations as a use case for interoperability

Prior authorizations are a fundamental use case for interoperability due to their pivotal role in healthcare operations. They have garnered attention from both payers and providers, driven by a mutual desire to improve efficiency and effectiveness of the review process. At the heart of this matter are two essential considerations: first, determining if a service warrants prior approval; and second, the assessment of its medical necessity.

The prior authorization review process remains heavily reliant on manual interventions, underscoring the urgent need to streamline submission and review workflows. By addressing this challenge through interoperability solutions, the healthcare industry can realize substantial benefits. Not only will operations be enhanced for providers and payers, but it would also cultivate greater efficiency and collaboration within the broader healthcare ecosystem.

Principle #2: Build on investments in a multi-payer portal and use a multi-payer API as a measurement for success 

Building on investments in a multi-payer portal is another component of advancing healthcare interoperability. Point solutions cannot adequately address the complexities of data sharing across different healthcare entities. A solution to this challenge would be for payers and providers to leverage a multi-payer portal and adopt standardized APIs to ensure seamless communication and data exchange.

However, to maximize adoption of industry standard APIs in the market, a multi-payer approach is needed. Adopting and normalizing industry standards promises to drive meaningful improvement in the cost of workflows like prior authorization, but it will require investments on both provider and payer systems. Ensuring these investments meet the broadest network impact will fall short of expectations if a point-to-point approach is required.

Additionally, APIs serve as a metric for success, particularly in workflows like prior authorizations, by providing quantifiable data at the speed and efficiency needed for the information exchange between payers and providers. Through APIs, key performance indicators such as response times, denial rates, and requests for information can be tracked and analyzed. This data allows stakeholders to identify bottlenecks, streamline workflows, and optimize processes, ultimately leading to faster authorization approvals and reduced administrative burdens. Furthermore, APIs facilitate real-time access to eligibility and benefit information, enabling providers to make more informed decisions and deliver timely care to patients. By leveraging APIs as a measurement tool, healthcare organizations can gauge the effectiveness of their interoperability initiatives and drive continuous improvement in healthcare delivery.

Principle #3: Leverage AI and clinical data to optimize additional workflows

There are a variety of use cases where AI can be leveraged in healthcare. But one area where these advancements shine is within utilization management, particularly within the prior authorization review process. AI can be trained to understand medical policy and quickly extract relevant information from clinical records to drastically streamline the prior authorization review process. Eliminating tedious back-and-forth conversations frees health plans and providers to focus on optimizing patient care.

Moreover, beyond its pivotal role within the prior authorization review process, AI’s capacity to extract and utilize clinical data offers a gateway to transformative opportunities in healthcare strategy and network performance optimization. Once clinical data has been gathered through a multi-payer portal for prior authorizations, it can also be used to support new strategic initiatives. For example, as fee-for-service models continue to give way to value-based care, payers can start using clinical data for business intelligence to help drive network performance. Additionally, effective clinical data use helps support:

• Identifying and closing care gaps
• Improved performance and reduced premiums
• Utilization management effectiveness
• Reduced medical costs and waste due to duplicative services
• Improved quality of care measures (Star Ratings/HEDIS^®/CAHPS^®)
• Social network analysis/complex network analysis

Because of the vast network we’ve created between payers and providers, Availity^® is uniquely positioned in the market to act as the “front door” within the healthcare ecosystem to support transactions across disparate systems and help reduce the challenges associated with interoperability. We’ve invested in cutting-edge technology like AI to support this effort. Prior authorizations are just the starting point to identifying additional use cases across the industry. If you’re interested in learning more about Availity AuthAI™ or want to schedule a meeting with our team, click here.

About the Author

Matt Cunningham, Executive Vice President of Product at Availity, brings a unique background with nine years of military service, including command roles during the Iraq invasion and subsequent counterinsurgency operations. Transitioning to healthcare, he has spent over 15 years addressing challenges in prior authorizations and utilization management. With a diverse career, Matt played pivotal roles in scaling a services company from $20M to the largest healthcare benefit services firm, serving in capacities such as Head of Call Center Operations, Director of Product Operations, CIO, and leading integration for mergers and acquisitions. In his latest role, he spearheaded innovation efforts automating prior authorization workflows. Matt also serves as President of the Vantage Point Foundation, dedicated to aiding post-9/11 veterans and their families in transitioning to civilian life.