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2022 NAHAM’s Prior Authorization Roundtable Recap

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Hear insights from our CEO

I had the honor of being asked to participate at NAHAM’s Prior Authorization Roundtable in October 2022 bringing together stakeholders from provider, payer, and vendor communities in an effort to stimulate discussions around potential solutions.  

 

Having spent time as a front-line provider requesting prior authorizations for my patients, a value-based healthcare researcher developing and implementing evidence-based pediatric surgical care pathways, and now as an entrepreneur looking to build technology infrastructure to automate prior authorizations, I found this discussion interesting from an unique vantage point of understanding all 3 sides. 

 

Several key points that were highlighted:

·        Payers are frequently constrained by either CMS defined coverage guidelines (NCDs – national coverage determinations, LCDs – local coverage determinations) and/or by contractual decisions made by employers in their sponsored plan choices.

·        Despite a desire to have standardized clinical guidelines across all payers, plans and their medical directors consider this as an area of competitive differentiation and/or a grey area where medical judgment is applied to the best of their abilities and within compliance with NCQA and URAC requirements.  

·        There is frustration on the part of payers on what is considered unnecessary care requests that are not justified by evidence-based guidelines and literature.   

·        For providers, each payer has its set of opaque prior authorization/pre-certification rules for different service lines, which all seem to be continuously changing.  Maintaining and managing all the different, shifting payer rules seems to be a Sisyphean task, one certainly not capable of being supported by today’s EHRs and practice management systems.

·        There is a need for a national clearinghouse for prior authorization transactions.  One that can seamlessly integrate into EHRs/PMS and act as a single interface for all payer prior authorization transactions.  Most agreed that the existing x12 278 standard does not adequately cover all the data elements necessary in a prior authorization transaction.  This is why there is little to no adoption outside of a limited set of notice of admissions workflows today.

 

There were several ideas that I took away from the conversation that I feel merit additional discussion:

·        Transparency on authorization requirements – a standard, machine-readable format from all payers to provide their established guidelines around specific sets of services.  This would include info on ICD-10, CPT/HCPCS/RxNorm, as well as any delegated benefit manager (eg AIM, NIA, eviCore, etc) and specific product information.  This would allow for providers to develop and maintain rules that can help better guide prior authorization requests and eliminate unnecessary errors/work.

·        List of which services do NOT require authorizations (“no auth required”) –  this would save a tremendous amount of time, cost, frustration, and delay for patients waiting for care.  This is an area payers can easily agree to as there is substantial cost generated from unnecessarily submitted prior authorizations, which still require review for compliance reasons.

·        “Open enrollment” period for payer authorization rule changes – create specified windows/periods of time during the year when payers can make changes to prior authorization rules.   This would help address the highly variable rule changes that frequently do not get recognized by provider teams.

·        A national clearinghouse for prior authorization data exchange.  This is the holy grail and what Voluware has been methodically building with our VALER all-payer, all service line payer network.  One place to 1) seamlessly integrate with EHRs/PMs, 2) comprehensively cover across legacy fax forms and web portals, 3) rapidly update and maintain changing payer rules.  

 

Certainly, we all hope that NAHAM and other organizations can keep the momentum going when it comes to offering practical, workflow-driven solutions to prior authorizations.  I hope that the spirit of collaboration and interest in real-world validation of innovative solutions continues.

Steve Kim, MD

Steve Kim, MD

CEO & Co-Founder Voluware, Inc.

Why Are Prior Authorizations So Manual?

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So why are prior authorizations such a manual process?  Whether it’s the joy of filling out paper fax forms, the carpal-tunnel inducing manual entry of data into payer web portals, or being on endless hold on the phone, prior authorizations today remain the bane of most practices:
  • The American Medical Association estimated that $31 billion is spent annually on prior authorizations by providers.
  • The Kaiser Family Foundation estimated 868.4 million hours are spent annually obtaining prior authorizations.
  • According to Milliman, manual prior authorizations cost $10.78 per transaction vs. $2.07 for an electronic transaction.  That’s $8.71 in savings per electronic transaction.
So one would think that in this day and age, that prior authorization transactions should be as easy as paying bills on your smartphone.  Guess again.  So why are prior authorizations still stuck in the  world of 1980’s fax tones?
 
1) Like politics, all healthcare is local.  Each geography has its own unique mix of providers, payers, and plans.  What that means, is that it is impossible to have any semblance of standardized workflows.  Each payer has its own fax form or clunky home-grown web portal that maps to its own internal workflows.
 
2) Local business requirements are always changing.  There are constantly changing forms or payer web portals.  Keeping up with change in today’s EHRs or practice management systems is impossible.  (How fast does your EHR vendor make changes? months? years? at all?)  Remember, these systems were never designed to manage change at the pace of the real world.
 
3) Everyone has their own system. None talk to each other today.   Whether it’s siloed provider EHRs or ancient payer systems, none meaningfully transacts electronic data with all their business partners.   It’s hard enough to get Cerner systems to talk to each other, let alone with say an Epic, Allscripts, or NextGen EHR.  And don’t even think about interoperating with a DOS payer system.
 
So, all healthcare is local, local business requirements are constantly changing, and none of our systems talk to each other.  What you get is $31 billion of last mile work-arounds to get anything done. We pay people to transcribe data on paper fax and type data into outdated systems.
 
This. Is. Insane.  As a physician working in the trenches, this is appalling and offensive.
 
This is why we have spent years studying the prior authorization problem. This is why VALER delivers automation today for prior authorizations, referrals, and eligibility.
 
To learn more, shoot me an email or message me: www.voluware.com steve@voluware.com @steveskim @voluware

Customer Love

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Customer love is a key metric for our company. All that (somewhat cheesy) stuff about loving your customers, who love you back, thereby creating a virtuous cycle: it’s true. It’s also one of things that powers Voluware. We passionately assert that we aren’t just software; we are truly software as a service.

 

So here’s what we do to feed the virtuous cycle of customer-Voluware love. It basically boils down to 2 main principles: (1) capitalize on VALER’s unique qualities and (2) cultivate customer communication.

 

  • Everyone in the company is on the customer support emails: from the CEO to sales and marketing to every last engineer. Because we customize our software to each client, it’s critical that we try to understand what it’s like to be in the user’s shoes.
  • A corollary of the above: no robotic email reply or ticketing system. We will put off a ticketing system for as long as we can because we want each user to feel the personal touch. This isn’t just benevolence on our part. It’s how we have a finger on the pulse of the customer and learn about new pain points that VALER can solve.
  • We insist on feedback. We tell our customers over and over again, “We can’t get you to where you want to be unless you talk to us.” We insist on it because, over 90% of the time, we can innovate or problem-solve right away. We don’t have to wait for a software release in a few months. We don’t have to put it into a queue. We can execute while the users are on the system. That’s the beauty of liveware – what we call a run-time changeable system. (For more on liveware, see our CEO’s blogpost from July 2018 on it). It’s ridiculously powerful and I can’t imagine doing it any other way.
  • Customizing VALER. The process of customizing VALER means we learn the workflows intimately. From kickoff to implementation and well into deploy, we have to maintain great communication or else the constant iteration to arrive at the ideal VALER won’t happen.

 

Recently, one of our customers was asked by another healthcare vendor to rate the implementation process in comparison to other software implementations. Our customer told another vendor and happened to tell me later as an afterthought: “We’ve never felt more supported with any other place company or vendor than the VALER team. VALER is all in and all they want is to for us to be as successful as we can while using their software.” I could not have asked for a better testimonial of customer love.

Why are prior authorizations so painful?

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So why are prior authorizations so painful?  As a young pediatric surgeon trying to build a practice back in 2012, this was precisely the question I asked myself every month as I looked through my accounts receivables (AR) reports.  Prior authorizations were consistently my largest source of denied payments and write-offs.  On top of that, prior authorizations were a constant source of frustration for both my office staff and for my patients in getting care delivered.  Fast-forward five years and it doesn’t seem like things have gotten much better with prior authorizations.  Some would even say that it has gotten worse with time.   That’s why I co-founded Voluware to create a smarter way to automate prior authorizations.
 
Here are some of the disturbing facts around the costs of managing prior authorizations:
 
1) The American Medical Association (AMA) reported an estimated $23 – $31 billion is spent annually by U.S. healthcare providers on prior authorizations.
2) A Health Affairs article in 2011 estimated that the $83,000 was the average spend per physician on interactions with insurance companies.
3) The Kaiser Family Foundation estimated that 864.8 million hours per year are spent by physicians on prior authorizations.
 
So why prior authorizations are so painful?  I’ll share some insights gained during my 5 year journey in understanding and fixing the thorny issues around prior authorizations:
 
1) Prior authorizations are extremely manual processes.  Whether it’s paper fax forms or typing data into a clunky payer web portal, the act of requesting a prior auth is an intensely manual activity.  In some of our time motion studies, it took around 16 minutes per authorization to fill out forms by hand and fax in.  It can be even worse when you need to call for an authorization as you face an eternity on hold.
 
2) Why are prior authorizations so manual?  Prior authorizations are so incredibly manual because of a fundamental lack of interoperability.   None of our existing information systems on the payer side and the provider side seem capable of meaningfully exchange data.  Within this gap, manual faxing or data entry into a web portal represents the lowest common denominator integration of the information the respective workflows of business partners.
 
3) Why is there no interoperability of information systems when it comes to prior authorizations?  Despite having an electronic standard for prior authorizations (EDI 278) for well over a decade, a fundamental inability handle the complexities of prior authorizations at a local level has hampered meaningful adoption.  Much like politics, all healthcare is, for the most part, fundamentally local.  That means local contractual agreements, local provider networks. and homegrown or outdated information systems never constructed to seamlessly transact data.
 
4) Why can’t information systems seamlessly transact data? This boils down to two very fundamental issues.  The first is that most systems, whether they are EHRs on the provider side or utilization management systems on the payer side, are old.  Like 1970’s MUMPS and DOS old.  These systems were never designed to keep up with the constantly changing business requirements and were certainly never built to talk to one another.   The second issue is the more challenging of the two.  Every system, whether it is on the provider side or payer side, is designed to act as its own source of truth.  Even if two systems were able to talk to each other, without an efficient method to reconcile and normalize the data between systems renders any brute force integration effort ineffectual.
 
Well, I hope that this was a useful primer on why prior authorizations are so painful.  Stay tuned as I delve deeper into the nuts and bolts of the above mentioned pain points, and show you how our VALER platform was designed to automate prior authorizations.  Please reach out if you would like to learn more: VALER® Team.

Run time changeable for dummies: “liveware”

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by Marty Staszak, CEO, Voluware, Inc.

Anyone else get frustrated when you have to stop work in progress because some application needs to upgrade itself? 

 

Lost all hope that the key feature you want will miraculously show up in some future product release? 

 

Wish you could get a software vendor to just add the features you want? 

 

If you’re already a Voluware customer, you have already embraced a whole new service delivery model for software and left these concerns in the past.  

 

Because I have to explain “run-time changeable software” to everyone, I have come to realize that it is difficult to do without some pain context. 

 

Our VALER platform is designed to automate payer-provider transactions using forms and portals. Forms and portals that we don’t have any control over and can change at any time.

 

If we had to do software releases every time a payer changed a form, or updated the demographics in a web portal, then our service would not be loved. In fact, it would not even be feasible.

 

To solve the “change at any time” requirements, we developed a platform that could be upgraded “immediately,” meaning, while it was running. Having solved the “change while it’s running” problem for the forms and portal transactions, we went a step further and extended it to pretty much all VALER business logic.

 

The end result is that many of the cool little feature updates our customers want are not just doable, they can often be implemented within a few days, or sometimes, a few hours, and in a lot of cases, a few minutes, with no service downtime.  

 

Can you imagine a software vendor that continuously updated your application according to your specifications on a release cycle measuring in days, with no downtime? Can you imagine if this is the way the relationship worked over the lifetime of your deployment? 

 

Unfortunately, a lot of prospective clients have trouble imagining this kind of world as it is so unlike the experience they get with other software products, especially in health care. We have a lot of other software vendors to thank for conditioning the health care industry to expect so little, and to suffer a lot of pain just to get what they want.

 

“Liveware” refers to a software application that can be continuously modified while running. Each VALER instance we deploy is liveware. Liveware applications can be evolved so fast that they allow for new project management practices to come to fruition. We call it “hyper-iteration.” A process that delivers 100 micro-updates to an application on a continuous basis over the course of a year keeps the application continuously stable and dramatically outpaces any other managed release process in terms of new features realized. It also allows us to immediately revert any new features that our customers change their minds about. It also allows us to juggle priorities and continuously change requirements.  

 

Feature creep got you down? VALER eats feature creep for breakfast!

 

We like talking about liveware. We love when our customers brag about it. Your VALER® “livewire” team member, is just a few clicks away: VALER® Team.

FQHCs: Falling behind on specialty referrals?

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We are currently working with FQHCs that had huge backlogs with specialty referrals due to the manual nature of obtaining prior auths and putting together referral packets. What we have done is to integrate their EHRs (NextGen, Intergy) with payer web portals and have digitized specialty referral fax forms to nearly automate the referrals process. We pull new physician referral orders directly from NextGen and auto-populate payer web portals for submission and retrieve authorization approvals. We have seen up to a 4X improvement in productivity around referrals with no increase in FTEs. Referral worklists that used to take a week to get through are done in days. We are also able to pull customized reporting on referrals productivity for managers. How are others handling this issue? I know that a lot of people are using i2i, but the integration with NextGen doesn’t seem that straightforward. If you have any interest in learning more please message me or email at info@voluware.com

Hmmm. Sounds like issues with Prior Authorization & Notice of Admission.

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Hmmm. Sounds like issues with Prior Authorization & Notice of Admission. NOA workflows can be intensely fax based as well. Some health plans offer an electronic 278 submission offering, but we are hearing that teams need to login to web portals to obtain authorization confirmation and tracking codes. To read the entire article click here: Family claims Atrium Health didn’t obtain pre-authorization prior to hospitalization.

 

Also, coordinating the auth/NOA approval with Case Management is key to getting clinical documents to the payer in a timely manner. VALER® has now added Notice of Admissions to automate fax and web portal workflows, provide date & time-stamped documentation of activities, and workflow collaboration between teams to avoid pesky denials.  #FixPriorAuth #VALER  #Patient Access  #priorauthorization  #AMA  #APGColloquium2020  #MGMA

 

How can VALER® help your organization? Ask us — a team member is just a few clicks away: VALER® Team.

Do You Still Rely on Paper for Your Prior Auths?

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Why is there still so much paper today with prior authorizations?

Prior authorizations today are still highly manual in nature because they require filling out a variety of paper fax forms by hand or mind-numbingly entering data into payer web portals. Exacerbating the process is that clinical and billing systems are not fully integrated – forcing staff’s reliance on collecting/reviewing payer prior authorization rules on paper or by scouring payer web portals and printing out rules for the patient’s specific insurance plan and storing in these in binders for future reference. Neither of these archaic methods of transmitting data would qualify as cost-effective, efficient, or of any real value.

 

Why are today’s information systems unable to talk to each other when it comes to prior authorizations?

These manual dependencies are a reflection of the inability of today’s legacy information systems to handle the complexities of prior authorizations and to fundamentally exchange information between differing source systems. Even today it is astounding the data exchange and interconnectivity has not been accomplished.

 

All business requirements are inherently local

Every practice has its own unique mix of contracted health plans, HMOs, and independent practice associations (IPAs), each with constantly changing business requirements. Conversely, every payer has its own constantly changing network of contracted providers and facilities (hospitals, labs, surgery centers, etc.). Multiply these changing relationships by the fact that each individual provider and payer has their own mix of legacy systems that were never built to meaningfully exchange data with other systems resulting in a significant amount of effort and time being wasted on the prior authorization process.

 

When no one speaks the same language

Because of the disconnect between healthcare organizations, there has been little (if any) adoption of EDI 278, the X12 electronic standard for prior authorizations. Beyond merely pulling data out of one system, the need to translate data into different source systems poses a significant challenge in achieving real interoperability. Compounding this issue is the inability of 278 to handle critical use cases needed to determine medical necessity for authorization requests. In the absence of the ability to handle prior authorization requests between systems, the lowest common denominator becomes manually translating information between different systems on paper fax or by manually keying data into payer web portals.

 

A mad, mad world 

As a real-world example of what occurs, my pediatric urology practice in Los Angeles dealt with over 150 different payer fax forms and over 20 different payer web portals. To obtain a prior authorization, my staff had to determine:

1) who the appropriate payer is,

2) which form or portal the payer requires, and

3) filling out fax forms or portals to transcribe information out of our EHR.

This process was costly both in terms of the time it took, and any errors which resulted in delays or denials.

 

Change at today’s pace

Because today’s legacy systems cannot keep pace with the ever-changing local business requirements, humans are needed on both provider and payer sides to manually translate data from one system to another. Paper fax forms and payer web portals are part of a crude exercise in data synchronization of information about mutual patients, providers, and facilities.

 

This is the last mile in healthcare, and this is not currently scalable nor sustainable with legacy systems. This is why we took a different approach to solving the prior authorization problem with VALER®.

 

Stay tuned as we look next at why legacy systems are not able to keep up with the pace of change in today’s healthcare environment and take a VALER® tour.

VALER® Prior Authorizations now in Epic App Orchard

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VALER is now available in the Epic App Orchard to support today’s manual prior authorization workflows.  Epic clients will now be able to bi-directionally integrate with VALER in order to further streamline today’s fax and web portal-based prior authorization submission workflows.  “With outstanding support from the Epic App Orchard team, VALER now has a clean, efficient, and cost-effective way to meet our clients’ needs around prior authorization workflows,” remarked Marty Staszak, CEO of Voluware and visionary architect behind VALER.

VALER provides one place to comprehensively manage, streamline, and automate today’s manual fax and web portal-based prior authorization workflows.  VALER offers clients a customized, integrated enterprise approach to taking back control of otherwise manual workflows with the goal of reducing cost, denials, and avoidable write-offs.  Key differentiators of the VALER approach to authorizations are:

  • Comprehensive prior authorization submission coverage (professional, facility, technical/ancillary, medications, DME, Worker’s Comp)
  • Real-time authorization visibility and coordination across the enterprise
  • Dynamic payer rules at submission to reduce denials
  • Run-time adaptability to keep up with the pace of payer change
  • Workflow-centric collaboration features

 

As a provider dealing directly with prior authorizations, Voluware co-founder Dr. Steve Kim knew that “VALER, from day one, had to be singularly focused on solving the day-to-day workflow challenges with prior authorizations.  Whether it’s fax, web portals, or phone calls, we had to do it all.  That’s exactly what VALER was built to do.”

 

About Voluware

Voluware provides innovative solutions aimed at reducing the cost of administrative transactions between healthcare providers and payers through the creation of mutually beneficial value networks.  VALER is a powerful cloud-based workflow automation platform addressing today’s manual prior authorizations and referral workflows.

 

To learn more about VALER contact us at Valer

 

Epic and App Orchard are trademarks or registered trademarks of Epic Systems Corporation.