End-to-End Prior Authorizations Using FHIR APIs

Challenge

Prior authorizations are a critical utilization management (UM) tool. These transactions are used to help ensure high-quality and cost-effective care delivery. Unfortunately, many providers and health plans consider the prior authorization process a burden due to manual interventions, analog technologies, and inconsistent standardization. Conventional prior authorization processes are complex and time-consuming, mainly due to substantial variations in payer requirements, limited adoption of an X12 278 prior authorization request, and challenges related to data management. As a result, provider staff are often tasked with reaching out to a patient’s health plan to supply the necessary demographic and clinical data needed to initiate the authorization process.

Solution

To address pain points within the prior authorization process, a collaborative initiative was launched by Humana, athenahealth, and Availity. The objective was to develop an automated end-to-end prior
authorization process leveraging the Da Vinci Burden Reduction Implementation Guides. This required analysis of the implementation guides and each party’s internal systems to define requirements for implementation. The participating organizations were diligent in their collaboration to clarify the exact details of the implementation. The joint approach to decision making was a powerful demonstration of what collaboration in the healthcare space can look like.

The workflow of the implementation and the distinct roles of each healthcare entity within the guides are detailed below:

Project Goals

To address prior authorization pain points, Humana, athenahealth, and Availity embarked on a collaborative initiative to develop an end-to-end prior authorization process leveraging the Da Vinci
Burden Reduction Implementation Guides. The goals of this collaboration were to:

• Improve transparency into the prior authorization process;
• Reduce the administrative burdens for both the health plan and its provider network;
• Leverage available clinical content; and
• Increase opportunities for automation

Overall Results

Outcomes were measured in the following ways:

Burden Reduction:

Evaluate time savings for staff by integrating real-time authorization determination capabilities. This initiative lead to an average of 17,585 orders with no authorization required, which saved provider staff about 4,396 hours per month that would have been spent verifying requirements for these authorizations.¹ Additionally, no authorizations were denied due to lack of documentation during the October to December 2023 evaluation period.²

Touchless Resolution:

Measuring the value of authorization determination capabilities and authorization auto-approvals. The stakeholders determined that during the evaluation period, nearly 54% of all requests per month required no authorization, and a monthly average of 70% of authorizations submitted through the
integration were auto approved.

Fast resolution:

Gathering required data elements up front allow for quick resolution of authorization requests, enabling providers to proceed with patient care. Between October to December 2023, the average time for an authorization to reach approval or denial status was 26 hours³ vs. industry averages that range from days to weeks.⁴ The 26-hour turnaround time on authorizations far exceeds the seven-day target established by the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).

The Da Vinci Implementation Guide specifications facilitate prior authorization decisions for payers by ensuring they possess the necessary information upon receiving the authorization request. This proactive approach represents a significant stride toward streamlining the authorization process, alleviating administrative burdens for both providers and payers. Most importantly, it reduces turnaround time, directly benefiting the care of members/patients.

In addition, the integration is embedded directly into the existing into the existing provider workflow, causing minimal disruption to daily operations. This seamless transition allows providers to swiftly proceed with downstream activities such as scheduling and care delivery. Beyond the benefits of speed and automation, this process provides comprehensive transparency into each authorization from start to finish.