Health organizations such as the American Medical Association (AMA), America’s Health Insurance Plans (AHIP), Blue Cross, Blue Shield and others are partnering to identify opportunities to improve the prior authorization process, with the goal of “promoting safe, timely, and affordable access to evidence-based care for patients; enhancing efficiency; and reducing administrative burdens.”
The Consortium met on January 17, 2018 and released a Consensus Statement on Improving the Prior Authorization Process. The statement addressed the challenges associated with the current process, relative to selective application, program review and volume adjustment, transparency and communication, continuity of care and automation.
Much like the goals of the Consortium, the cross-specialty Innovation Messaging Taskforce Group (ITG), led by Secure Exchange Solutions CEO Dan Kazzaz, is working to address the need for standardized communications for complex exchanges that take place between payers and providers. This next level of structured formats will contribute to improved workflows by streamlining prior authorization, claim attachments, HEDIS reporting and more.
The ITG was formed to address the very needs outlined in the consensus statement, specifically, identifying the lowest cost, most scalable set of standards to help the healthcare industry improve prior authorization. The group believes that using technology and standards already embedded in the EMR is the fastest path to solving this very important, but burdensome, process.
While technology solutions could reduce the burden of the process for providers and payers, collaboration is necessary to ensure software solution providers that are physician-facing do not implement unique solutions based on single payer needs. To date, there is no single set of standards that can resolve the complexities of the process. Rather, to establish an automated process, the solution will likely require combining (and perhaps improving) multiple standards for this effort.
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