Blue Cross Blue Shield of Massachusetts said its prior authorization pilot at Boston-based New England Baptist Hospital significantly reduced prior authorization approval times.
The pilot program, called FastPass, focused on hip and knee procedures for 32 orthopedic providers over the course of four months, according to an Oct. 12 BCBS news release. Eighty-eight percent of prior authorization submissions were processed automatically in real time. Prior authorization approval times went from an average of nine days to an average of less than one day.
"We realize that the prior authorization process is widely recognized as the single biggest administrative pain point for hospital staff," said Kathy Gardner, RN, vice president of clinical operations at BCBS. "We wanted to figure out a way to retain the value of prior authorizations — ensuring our members receive treatments that are medically necessary and clinically effective — while eliminating the administrative burden on our clinical partners and allowing members to get the care they need sooner."
Four things to know:
1. BCBS partnered with artificial intelligence company Olive for the pilot. Olive's AI technology automated the process of cross-checking the payer's prior authorization requirements in real time to identify if a prior authorization was required.
2. If prior authorization was not required, the provider received an instant notification that it could move forward with scheduling a procedure.
3. If prior authorization was required, FastPass used AI to cross-check the clinical history in the EMR against BCBS' medical necessity criteria and automatically generated a recommendation in real time.
4. For prior authorization submissions that required more complex clinical review, FastPass automatically packaged and made available all the clinical documentation and notes to the clinical review team, significantly streamlining and accelerating the reviews.