Availity’s Authorization Solution

Challenge 

Health plans and providers don’t always see eye to eye, but when it comes to prior authorizations there’s strong consensus that the process isn’t ideal—for anyone. For this reason, one regional Blue plan in the Midwest was looking for a way to improve the process for itself and for its provider network. 

The health plan had conducted an internal assessment and found that 40 percent of its call center volume was attributed to authorizations. Additionally, they had a highly manual utilization management process that required staff to enter all incoming faxes into the system for review by clinicians. The plan estimated calls in to the call center cost between $5-7 per call, while the total cost of each fax was approximately $13-15. They believed improving the process could drive significant savings. 

 The plan’s providers were also slowed down by manual workflows on their end. It was difficult to determine when a procedure required a prior authorization, so providers would go through the process of submitting them even when they weren’t necessary. They were also unsure of when they were supposed to submit an authorization to the plan versus the plan’s utilization management vendor. One of the biggest challenges was keeping track of the status of submitted authorizations, and many relied on sticky notes and Excel spreadsheets to manage them. 

Driving adoption through training and communication  

The health plan conducted a soft launch of the authorization solution in June of 2018. At the end of the year with provider adoption hovering around 43 percent, they decided to take an aggressive approach by setting a cutoff date for faxes and mandating the usage of Essentials by May 1, 2019. They then partnered with Availity’s Client Engagement Services Team to develop a robust training, deployment, and communications plan to support the migration.  

Client Engagement Services created a multi-faceted program that included online and in-person training on the tool in addition to job aids that reinforce some of the more challenging areas. The plan and Availity closely monitored training enrollment and attendance and revised the messaging as necessary. There was also a call campaign where Availity reached out to targeted providers to drive utilization. 

Results 

The plan set a target goal of achieving 70 percent provider adoption by the end of 2019. In May—seven months ahead of schedule—they hit their goal. The training sessions were widely attended, and the health plan was able to turn off the fax machine as scheduled with no increase in call center volume.

With the rollout of the authorization solution, the plan is projecting $3.9 million in administrative savings over the next three years. There is also evidence of decreased call volume now that providers can check for themselves if an authorization is required.

Reviews from providers have also been positive. They like the intuitive workflow and the ability to upload, rather than fax, documentation. But some of the biggest kudos have been for the dashboard. “We can see on our dashboard right away which cases we have started and if they are in review, pending, or denied. It is nice to see everything in one view.”