Posts Tagged ‘clinical documentation’

Guest Post: 6 Barriers to Automating Prior Authorization

October 3rd, 2019 by April Todd

Automating prior authorizations could save the healthcare industry $417 million annually.

Prior authorization has been used for decades as an important check to ensure prescribed medical treatment is safe and appropriate. In recent years, however, it has become regarded by many as a frustrating, time consuming barrier to care.

Much of the frustration has to do with the fact that the overwhelming majority of prior authorizations are conducted using manual processes that can take days, and, in some cases, weeks, delaying patient care. Prior authorizations are also a financial burden on providers and plans. So much so that the industry could save $417 million annually if these transactions were automated, according to the 2018 CAQH Index.

In spite of the widespread frustration, the number of prior authorizations increased by 14 percent in 2018 over the previous year.

Increasing automation seems like an obvious solution, especially when there has been a federally-mandated standard for automating part of the process for more than a decade. But that just is not happening fast enough.

A recent CAQH CORE, an organization formed by the industry to develop common business rules to support healthcare transactions, white paper, identified six factors that have slowed end-to-end automation of prior authorization:

  1. Data is inconsistent

    Health plans use codes to communicate status, errors and next steps for prior authorizations—including the need for clinical documentation to prove medical necessity. But today, these requirements differ across (and within) health plans, and providers can’t easily identify what information is required. This lack of uniformity— and use of overly generic codes— limit adoption of the standard prior authorization transaction by providers.

  2. No federally mandated standard for “attachments” or clinical documentation

    As part of standard prior authorization requests, providers are asked to include “attachments” or clinical documentation. However, there is no national standard or uniformity for the supporting clinical documentation. This creates a sense of uncertainty about investments in various solutions, and results in workarounds that providers are asked to support.

  3. Lack of integration between clinical and administrative systems

    Electronic prior authorization requests typically require the use of practice management systems (PMS) and data from electronic health record (EHR) systems. But integration between PMS and EHR systems is limited. This forces most providers to retrieve clinical information from the EHR and manually enter it into the prior authorization request. This is not only an obvious source of human error, but also a frustrating drain on productivity and efficiency.

  4. Limited vendor products that support electronic prior authorization

    Only 12 percent of vendor products support electronic prior authorization, according to the 2017 CAQH Index. For all other electronic transactions, vendor support is between 74 percent and 91 percent.

    Some vendors indicated that, while their systems do currently support prior authorization, this functionality is not part of the core product offering. That is, prior authorization functionality may be available in some vendor systems, but only in a premium configuration.

  5. State requirements for manual intervention

    Some state legislatures have mandated that certain steps of the prior authorization process be handled manually. For example, in both Colorado and Rhode Island, health plans are required to give providers an opportunity to speak directly by phone or in person with a qualified medical professional before issuing an adverse determination. Some of these manual requirements are in place because a phone call or written letter may be a more trusted mode of receiving communication regarding determinations.

  6. Lack of provider awareness

    Many providers are unaware that HIPAA requires health plans to offer the standard prior authorization request to conduct prior authorizations electronically. Greater demand from providers can incent broader use of the standard and encourage development of vendor products to support its exchange.

How Do We Get to Automation?

Currently, there is a groundswell of support from a diverse group of stakeholders to improve the prior authorization process. The Department of Health and Human Services, federal and state policymakers, providers and health plans, industry coalitions and standard-setting organizations are all motivated to resolve the administrative burden associated with prior authorization—creating an unprecedented opportunity to find alignment and implement solutions.

So, Where Do We Start?

To reduce the prior authorization burden, it is important for all stakeholders to participate in developing standards that support automation, and follow them. CAQH CORE’s participating organizations, which encompass 75 percent of insured lives, have developed two sets of operating rules that are already addressing several of the challenges identified above. By adopting the Phase IV and V CAQH CORE Operating Rules, and participating in CAQH CORE’s prior authorization pilots, healthcare stakeholders can help accelerate the move toward automation of prior authorization.

This renewed spirit of collaboration is the pathway to reducing the prior authorization administrative burden. It is imperative for all stakeholders to actively encourage and participate in this collaborative momentum toward a more automated prior authorization end-to-end workflow.

April Todd

April Todd

About the Author: April Todd leads CAQH CORE, an initiative of CAQH that was formed to drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability and align administrative and clinical activities among providers, payers, and consumers. CAQH CORE is industry-led—representing more than 75 percent of insured Americans, including health plans, healthcare providers, vendors, government entities, and standard setting organizations. Five phases of CAQH CORE Operating Rules and Certification Test Suites have been issued to date.

Infographic: Clinical Documentation to Optimize Value-Based Care in the Outpatient Setting

June 22nd, 2018 by Melanie Matthews

A strong commitment to clinical documentation improvement (CDI) can help healthcare organizations maximize claims reimbursement while improving quality of care, according to a new infographic by Galen Healthcare Solutions.

The infographic examines CDI goals and the impact of improved CDI on the healthcare bottom line.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: EHR and Clinical Documentation Effectiveness

February 27th, 2017 by Melanie Matthews

EHR and Clinical Documentation EffectivenessInformation technology and healthcare leaders are looking at ways to improve electronic health record (EHR) and clinical documentation effectiveness, according to a new infographic by Nuance Communications, Inc.

The infographic examines the strategies healthcare organizations are implementing to improve clinician satisfaction with EHRs and how organizations are optimizing EHRs this year.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results Between Medicare’s aggressive migration to value-based payment models and MACRA’s 2017 Quality Payment Program rollout, healthcare providers must accept the inevitability of participation in fee-for-quality reimbursement design—as well as cultivating a grounding in health data analytics to enhance success.

As an early adopter of the Medicare Shared Savings Program (MSSP) and the largest sponsor of MSSP accountable care organizations (ACOs), Collaborative Health Systems (CHS) is uniquely positioned to advise providers on the benefits of data analytics and technology, which CHS views as a major driver in its achievements in the MSSP arena. In performance year 2014, nine of CHS’s 24 MSSP ACOs generated savings and received payments of almost $27 million.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results documents the accomplishments of CHS’s 24 ACOs under the MSSP program, the crucial role of data analytics in CHS operations, and the many lessons learned as an early trailblazer in value-based care delivery.

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Infographic: Clinical Documentation

September 5th, 2014 by Melanie Matthews

Correct coding based on complete clinical documentation boosts first time clean claim rates and decrease denials.

MRS Information Services has developed an infographic that details the regulatory impacts of correct clinical documentation and how to improve your health information management department for maximum performance. The infographic also highlights how ICD-10 will impact healthcare organizations and how organizations are preparing for ICD-10.

Electronic Health Records: Strategies for Long-Term Success Electronic Health Records: Strategies for Long-Term Success is a comprehensive reference for the design, implementation, and optimization of electronic health records (EHRs). The authors offer a detailed road map for avoiding common pitfalls during conversion and achieving higher-quality care after system implementation. A glossary of important terms and references to additional resources are also included in the book.

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