Health systems have to take responsibility for the broken prior authorization process and stop deferring action to payers, according to Jeff Balser, CEO of Vanderbilt University Medical Center.
“A lot of the work and time and delays with prior authorization are actually on our end,” Balser declared last week during a panel at Forbes’ Healthcare Summit in New York City.
He noted that providers can begin the prior authorization process as soon as an appointment is scheduled. Many denials aren’t because the service is inappropriate, but because the provider failed to include the right information, he explained.
Balser stressed the need for health systems to support clinicians with better workflows, as well as centralized teams so that physicians aren’t doing this work alone.
He also pointed out that AI can significantly reduce the burden of prior authorization. Vanderbilt is using machine learning tools in its clinics to surface exactly what information is required for each payer to approve to request.
“The information that the insurance company needs is all in the health record, and so we’re actually starting to work on AI processes that can autonomously collect the needed information for a prior authorization and simply have the clinician approve it, and off it goes — so that we aren’t wasting everybody’s time,” Balser remarked.
Partnerships with payers are still essential, though, he noted. He pointed to two key areas where Vanderbilt is working closely with payers: standardization and gold-carding.
Balser said the health system is collaborating with payers to make prior authorization requirements more consistent across plans, as well as implementing a policy that exempts clinicians from prior authorization in clinical areas where their approval rates are already extremely high. This approach, often called gold-carding, removes thousands of unnecessary reviews and speeds care for patients, he stated.
Balser’s co-panelist — Steve Nelson, executive vice president at CVS Health and president of Aetna — believes that partnerships between payers and providers are not only possible — they’re essential.
“There’s a myth out there that payers and providers cannot work together. I’ve led organizations in both spaces, and I’m telling you that it’s not true. We do not despise each other,” Nelson declared.
As for Aetna’s internal efforts to innovate the prior authorization process, he said the payer is launching new programs for bundling and better data exchange.
Instead of separate authorizations for drugs, procedures and follow-up care, Aetna now offers a single prior authorization for care episodes, such as a round of IVF, a cancer care journey or the management of a musculoskeletal condition.
Nelson also noted that Aetna is replacing “archaic” data exchange methods with faster, more accurate networks so that the right decisions can be made quickly.
Photo: Andrii Yalanskyi, Getty Images
