How 5 payers are reforming prior authorization systems

Though providers have been largely critical of payers for what they say are slow or ineffective prior authorization reforms, these are five innovative systems introduced by payers this year: 

BCBS Massachusetts said Oct. 12 it partnered with AI company Olive for a prior authorization pilot at Boston-based New England Baptist Hospital. Eighty-eight percent of prior authorization submissions were processed automatically in real time, and approval times went from an average of nine days to an average of less than one day.

Regence and MultiCare Connected Care in Tacoma, Wash., said Oct. 11 they have launched the nation's first HL7 FHIR-based prior authorization system to allow providers to submit requests directly from MultiCare's EHRs.

Blue Cross Blue Shield of Wyoming and Eden Prairie, Minn.-based Itiliti Health said May 2 they are partnering to create a cloud-based automatic prior authorization system for providers. The new system will allow providers to quickly determine if they need to submit a prior authorization request without contacting BCBS and has been shown to reduce requests by 30 percent.

Optum on Feb. 17 launched Specialty Fusion, a new solution from the UnitedHealth Group subsidiary that allows payers and providers to manage specialty drug treatments with real-time data. It also looks to address burdens associated with prior authorization by giving providers the ability to kick off the approval process from one portal.

Florida Blue became the first U.S. payer to use AI-powered clinical reviews to automate its prior authorization process in February through a partnership with Olive. The company said requests with immediate responses saw turnaround timelines shrink by 10 days and unnecessary requests were reduced by 27 percent.

Another large prior authorization reform from a healthcare organization this year was the Ohio Hospital Association partnering with Columbus-based Rhyme in June to improve efficiencies within prior authorization at hospitals and health systems across the state. The platform replaces the process with intelligent collaboration between payers and providers by integrating into providers' existing workflows to make interactions faster.

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