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.