The steps required to ensure that the recommended procedures meet member coverage guidelines can be labor intensive, resulting in both patient and provider frustration, as well as delays to needed care.
During an executive session sponsored by Olive at the Payer Issues Roundtable and hosted by Becker’s Payer Review, Jim McDonnell, SVP of Growth for Olive’s payer team, facilitated a discussion between Tina Cummings, Vice President of Clinical Operations & Performance, and Tina Cornell-Miller, Senior Director of Healthcare Services Business Performance, who are both from GuideWell – the parent company of Blue Cross and Blue Shield of Florida, known as Florida Blue. The GuideWell executives shared their previous challenges with prior authorization and how a solution from Olive has helped them to deliver prior authorization decisions at the point of care.
The four key takeaways were:
- GuideWell faced fierce market competition and was challenged to offer affordable products that often required prior authorization. According to Tina Cummings, Florida Blue serves about four million people in its commercial book of business. “It is a very competitive market,” she said. “In any county, we have about 10 different competitors for every customer that we are trying to either maintain or acquire.”
Tina Cummings explained that affordability is a major driver for members. “Some of our most affordable products at Florida Blue are HMO products, and these products require a gatekeeper,” she said. “Prior authorization is not going away. There’s always going to be more regulation. So, our prior authorization strategy was focused on how we could do it better than everybody else.”
- Prior authorization management is a labor- intensive function for both providers and payers “It was eye opening to understand the total cost of prior authorizations for us,” Tina Cornell-Miller said. “It’s much more than just that authorization request . It’s the FTEs required to manage the process. It’s the customer service rep who needs to listen to members calling about their authorization to figure out their next step in Care. These were barriers that weren’t allowing us to be best in class.”
- Olive helped GuideWell deliver a prior authorization solution at the point of care. “When physicians determine a member needs a prior authorization, they write the order in the EMR,” Tina Cornell-Miller explained. “Through the Olive solution, providers upload their records, the artificial intelligence determines if that record meets our medical coverage guidelines and an answer is provided. By the time that physician walks down the hall, they have an answer. We did not want members to leave the physician’s office not knowing their next step.”
- Delivering prior authorization at the point of care has delighted providers and patients, reduced escalations as well as other related delegated vendor issues and proven that prior authorization can be a seamless process with AI. Providers are notified when a prior authorization request is not necessary and the turnaround time using the Olive solution delivers decisions that are approved within 90 seconds. 78 percent of submissions have been completed by artificial intelligence, requiring no human intervention. The Downstream payer-related impact on escalations has been reduced by 70 percent. “We know that if we can deliver prior authorizations at the point of care, we can differentiate ourselves from other payers and delight our Members ,” Tina Cornell-Miller said, “and that’s what we’ve been able to accomplish.”
By moving prior authorizations to the point of care, GuideWell (Florida Blue) has differentiated itself in an ultra-competitive market while improving the experience for members and providers
