AVIA Marketplace is the leading online resource for accurate, unbiased information about digital health companies and solutions. Our goal: To empower hospitals and health systems with the information they need to match with vendors who can meet their unique needs. We asked the top companies in the prior authorization space about their solutions and what they think the future of digital health looks like. No sponsored content or advertorials—just transparency and insights that decision-makers can use.
Through its namesake unified platform, Change Healthcare, now part of Optum Insight following the recent completion of the company merger, offers a suite of solutions designed to improve clinical and financial outcomes for providers, payers, and consumers across the care journey. Within the prior authorization space, Change Healthcare offers eligibility and patient access tools to help providers more efficiently obtain pre-service authorization while creating additional financial transparency for patients.
Archie Mayani, SVP and Chief Product Officer, leads Change Healthcare’s Clinical Decision Support business, where she oversees product development teams working to deliver evidence-based clinical content for payers and providers. Prior to joining the leadership team at Change Healthcare, she led Amazon’s Product and Content Operations team and led multiple teams at Optum. Archie began her career as a biomedical engineer, working her way through diverse product and business roles at GE Healthcare, Philips Healthcare, and Milliman Care Guidelines. She earned her master’s degree in biomedical engineering from the University of Florida and an MBA in Mergers and Acquisitions from the University of Warwick in the U.K.
Q: Can you tell us about your company and the challenges you are solving within the prior authorization space?
A: Change Healthcare is focused on enabling a better, more efficient healthcare system through the power of the Change Healthcare platform. Our goal is to help payers, providers, and consumers improve clinical and financial outcomes so that everyone in the healthcare system can thrive. Despite all the automation innovations that exist today, authorization automation remains a complex challenge. Although the industry has recognized some success, many gaps still exist that require costly human intervention. The manual nature of prior authorization, the need for clinical documentation, and payer connectivity are some of the challenges Change Healthcare is solving today.
As part of our overall authorization solution, Clearance Authorization is an industry-leading module of our Clearance Patient Access Suite. Clearance Authorization determines if an authorization is needed. The solution houses authorization policies from more than 600 payers representing more than 90 percent of covered lives in the U.S. Its authorization policy database is routinely and automatically updated to ensure actions are taken on the most up-to-date set of payer policies, keeping the provider compliant with payer-authorization requirements. With Clearance Authorization screening rules, the provider increases productivity and reduces the cost of cumbersome manual touch points and time-consuming phone calls.
Authorization Submission automates the manual process of prior authorization. The solution electronically submits the prior authorization request and monitors pending prior authorization decisions and updates the EHR or practice-management system. Today, we have EDI connections to more than 40 payers using the HIPAA required X12 278, and we use robotic process automation for 150 payer connections.
To assist with the completion of inpatient medical reviews, hospitals use InterQual® AutoReview. This is a cloud solution for providers who want to apply AI to real-time data extracted from the EHR for patient-specific prediction and proactive insight while automatically completing the InterQual® medical review. This can reduce the manual entry of criteria by 70 percent on average and automatically complete some medical reviews without user intervention. This completed review, along with the clinical data, is shared with the integrated payer.
In addition, the solution automatically obtains payer pre-authorization decisions from more than 175 payers and returns the approval and authorization number back to the EHR or practice management system as soon as they are available.
Q: How does your company differentiate from other vendors in the same category?
A: We are integrated with 15 different EHRs to automate authorizations and have a connected footprint of more than 150 payers and more than 2,000 hospitals. Our solution is the first scalable nationwide solution that leverages the InterQual content and the Change Healthcare Medical Network for payer integration and the sharing of clinical reviews. In addition, our clinical content team actively manages payer prior authorization rules and notifies providers when an authorization is required, reducing the unnecessary manual work at the beginning of the process. These rules are compared with claims and remittances that Change Healthcare processes to ensure that the rules are accurate.
Some providers struggle with staffing that technology alone can’t address. Our Connected Authorization Services offering uses Change Healthcare authorization technology and our staffing expertise to help improve authorization efficiency. We deploy pre-authorization experts who use our intelligent authorization technology to help handle routine authorizations rapidly and work complex cases by exception to optimize the efficiency and accuracy of medical authorizations. This can be a fully outsourced solution or a hybrid approach, which gives providers the flexibility to build and scale capabilities to suit their specific needs, prevents unnecessary care delays, supports accurate reimbursement, and reduces the cost of medical authorization efforts.
Q: What are some of the biggest changes your company has seen around how health systems are approaching prior authorization, given the changes in the landscape over the past couple of years?
A: Health systems understand that there isn’t a silver bullet for authorizations and that no one vendor has connections to every payer or can automate every step in the process. Providers have complicated workflows because they work with many payers in multiple portals and with numerous vendors. Providers are looking at vendors who align with their vision of authorization and who they believe offer long-term solutions. They look for partners who work with payers and understand how to most efficiently solve the problem of prior authorization.
Q: What does an ideal client look like? How are health systems or health plans best organized for success in standing up prior authorization and adjacent capabilities?
A: For our authorization solution, there isn’t a single ideal customer. We work with nationwide health systems, community hospitals, as well as health plans. Some of our customers focus on specific provider use cases, such as ambulatory surgery centers, infusion centers, or vendors of durable medical equipment. Health systems that are well-suited for success with prior authorization typically have clear lines of communication and a strong focus on collaboration. This helps ensure that all relevant stakeholders are involved in the process and that there is a shared understanding of the goals and objectives. The customers who are organized for success understand that this is a partnership to address the authorization burden.
Q: What measurable outcomes have you seen from your clients?
A: The first step in our process is to compare authorization requests with our “Is Auth Required?” rules. Upfront recognition of whether an authorization is necessary offers significant time and cost savings. In most cases, we see that about 15 to 20 percent of the authorizations our solution receives don’t require authorization. Some providers see about a 40 percent reduction in authorizations with our authorization screening tool. In addition, customers have seen up to 70 percent of their authorizations benefit from some level of automation with their payers. This number is based on the provider’s payer mix and set of services.
InterQual AutoReview offers a unique blend of AI, automation and evidence, which helps case managers be more efficient, proactive, and insights-driven to improve clinical and financial outcomes. Real-time predictions are delivered when it matters most and are continuously updated throughout the patient’s stay. This automation eliminates 75 percent of the work required for the initial clinical review process.
For Clearance Authorization status updates, our solution has found the final determination for more than 70 percent of our customers’ prior authorization requests. This metric is dependent on the specific payers and services for the provider.
Q: What major functional enhancements and/or product investments are you making in the near term to keep up with the evolution of automation?
A: This spring, we will expand our integration for single sign-on using Smart on FHIR integration. This is a move to add FHIR APIs to our existing 278 and HL-7 integration options and will allow users to stay within their EHR workflow. The solution uses our application for FHIR connections to gather clinical data from the EHR as part of the submission, reducing the manual process of uploading documents. Our integration with payers is also expanding with direct API integration for the Da Vinci FHIR CRD and DTR workflows, as well as the addition of the InterQual Medical Review Service feature Review Share, which allows connected providers to electronically share InterQual Medical Reviews with their connected payers. Further payer integration to support more clinical documentation uploads and faster approvals will also be offered.
Q: How is your company partnering with clients as reimbursements and use cases shift?
A: Our authorization conversation starts with understanding the provider’s needs. Are they looking for a technology solution for their staff, a service offering to reduce their costs, or a hybrid model to allow for scale and flexibility? We build on this solution by discussing specific use cases (inpatient, ambulatory, or specific service lines), and then we add our integration with payers. In many cases, we work jointly with payers and providers to solve the authorization workflow together.
Q: What are the biggest opportunities health systems should be thinking about this year when it comes to automation?
A: With the newly released CMS proposed rule and the mandate for inclusion of new standards for electronic authorization, now is the time for discussions with vendors on the prior authorization road map and how they believe they and the market will respond. These conversations should include means of reducing the amount of time and resources spent on manual prior authorization processes, improving the accuracy and completeness of prior authorization submissions, and increasing overall efficiency and productivity. By focusing on these opportunities, health systems can improve their prior authorization processes while improving the patient experience.
Q: How do you see the prior authorization space evolving in the next two to five years and beyond?
A: The new proposed rule published by CMS in December 2022 aims to overhaul prior authorization by streamlining requests and the sharing of healthcare data. These new authorization requirements should align providers, payers, and vendors to address the prior authorization burden. This requirement for Medicare Advantage, Medicaid, and exchange plans mandates that electronic prior authorization be built around the X12 278 HIPAA standard, supplemented with APIs for sharing of the medical guidelines, electronic submission of prior authorizations, and to know when an authorization is required. The CMS requirement focuses on reducing the burden of prior authorization. Companies with payer and provider integration along with medical guidelines and automation tools will be the partners that health systems will want to work with in this quickly evolving landscape.
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