Independence Blue Cross and Philadelphia-based Penn Medicine are piloting a program that allows qualifying physicians to skip prior authorization approvals needed for ultrasounds, CT scans and PET scans.
To qualify, physicians must have a consistent record of ordering medically necessary radiology tests such as CT scans and MRIs in a way that is consistent with accepted guidelines.
Rodrigo Cerdá, MD, Independence Blue Cross' senior vice president of Health Services and chief medical officer, spoke with Becker's about how the pilot come about and how it benefits the payer.
Editor's note: Responses have been lightly edited for brevity and clarity.
Q: How did this pilot program come about?
Dr. Rodrigo Cerdá: Penn has been working for a while on decision support for their providers through their medical record system. So they have decision support at point of care saying, "Hey this is likely to be appropriate or not." Then they have a report card for their providers that kind of tells them how they do compared to their [previous] years. And over the past couple of years they've been able to improve their performance judged by how many denials we have of their care because they're actually following guidelines and being good stewards of the healthcare dollar.
As we looked at that, we felt like there was an opportunity there, and they brought their denial rates down to a certain level and they knew how each of their providers fared. We came up with a program that allows providers that have a track record of performing well […] to basically notify us that they're ordering it and not have to go through the authorization process, which is a win for everybody. Less administrative burden on providers, they get a fast turnaround, basically instantaneous turnaround on an authorization, and, at scale, it would introduce efficiencies for us as well.
I would say it's a trust-but-verify approach where we both agree that we're doing this, but we are going to be monitoring overall trends. We will have the ability to audit and make sure retrospectively that the orders and the imaging that's done was appropriate. And there are consequences. If the trend is off and the audit shows it's not justified, Penn would have accountability for when it goes off the rails. And also individual [physicians] that are not following their own guidelines have the ability to lose their privileges of having this ability to get an auto authorization.
Q: How does Independence benefit from this program?
RC: Number one, we have an incentive to have a better provider experience. We see our provider network as partners. So we would rather have them have a good experience of working with us. So that is something that we do look at as we think about the broader relationship.
Number two, we obviously want to have a very good member experience and, to the extent the authorization process can be faster and less cumbersome, we want to do that from the point of view of a member who wants to get the imaging and wants to have certainty that it will be approved.
Number three, doing this process of precertification does have a degree of cost to it. In this case, the savings for us administratively is not really significant. But I think we feel, at scale, it could be, and we would always look to invest any that dollar that we have, we look to invest it somewhere else where it can be used better.
I feel like precert is one of those things where, if we could come up with a better solution to it that was still a really good steward of the healthcare dollar and was insurance for the high quality of care, we should try to do that. I think this is the ability to do it with good safeguards.
Q: Is this something that could be rolled out with other health systems if this pilot is successful?
RC: We are having discussions with other health systems even now. [...] I think the caveat there is that for Penn it did take work for them to get to the point where it makes sense to do this. They did implement processes that really optimized how they work and that enabled us to have a degree of data that gives us a degree of transparency on what's going on. So we do want to do this. We would love to do this, especially if it works well because we would want to do this on as much scale as possible. But we want to make sure we do it right, and that's not always easy to do with a snap of the finger.