AHIP and several prominent health insurance providers – covering over 60 million lives – are launching a new program to automate and speed prior authorization review and approval
WASHINGTON, D.C. – Patients deserve access to the safest, most effective and highest-quality care. To achieve that goal, health insurance providers may use prior authorization – a systematic approach based on clinical evidence and data that ensures patients receive safe and effective treatments. Today, America’s Health Insurance Plans (AHIP), along with several of our member insurance providers, is launching the Fast Prior Authorization Technology Highway (Fast PATH) initiative to improve the prior authorization process.
Electronic prior authorization is becoming more available to physicians but most still use manual processes to request prior authorizations, despite the common availability of online submission portals – with 46% of requests submitted by fax and 60% requiring a telephone call. Fast PATH aims to employ technology in the physician’s office to improve connections between insurance providers, doctors’ offices, and other care settings. This new initiative will rely upon the proven automated technologies of both Availity and Surescripts to speed prior authorization requests, responses, and information exchange.
Participating Insurance Providers Include Leading Companies Covering Tens of Millions of Americans
Participating in components of Fast PATH include a diverse set of leading health insurance providers that collectively cover over 60 million Americans: Anthem, Blue Shield of California, Cambia’s affiliated health plans, Cigna, Florida Blue, and WellCare.
“When patients do better, we all do better. Patients should receive the right treatments and medications at the right time in the most effective and efficient way,” said Matt Eyles, President and CEO of AHIP. “That’s why we’re committed to reducing unnecessary burden, increasing patient satisfaction and improving quality and outcomes.”
Fast PATH will address two common but critical prior authorization applications – one focused on prescription medications, and the other on medical and surgical procedures. Here is how they will work:
- Improving prior authorization for prescription medications. Using Surescripts technology, critical information will be available at the doctor’s fingertips while the patient is still in the office – informing the prescribing process, reducing surprises at the pharmacy counter, and making it more likely the patient will receive and take the medication. Together, this should promote better patient outcomes.
- When a doctor prescribes a medication through an electronic health record (EHR), they can immediately access the patient’s pharmacy benefits, know whether the specific medication requires prior authorization, and have the information to choose an alternative treatment that is clinically equivalent but more cost-effective and does not require prior authorization.
- If the doctor prescribes a medication that requires prior authorization, the doctor can immediately submit the approval request through their EHR.
- The doctor will also have access to the patient’s out-of-pocket cost for each drug, so the patient will know what to expect to pay when picking up the medication at their pharmacy.
- Improving prior authorization for medical and surgical procedures. Using Availity technology, doctors and surgeons can access a multi-payer portal to simplify prior authorization requests that may be required for a surgery or other procedure. The portal allows for easier communication and faster approvals, thus speeding the delivery of quality care for patients.
- When care providers or their staff order a procedure for a patient, they will know immediately whether the procedure requires prior authorization based on the patient’s specific health insurance coverage.
- If prior authorization is required, the provider can easily submit the necessary information through the Availity portal to fulfill the request, avoiding time-consuming phone calls and interruptions to patient care.
- The health insurance provider will review the information, make a determination based on the patient’s coverage and treatment evidence, and send a response through the portal.
- The provider and staff can also manage all of their prior authorization requests through the user-friendly dashboard in the portal.
Expert Partners to Advise Fast PATH Pilot Initiative and Evaluate Results
To evaluate the results and gather key learnings on deploying these technologies, AHIP will utilize RTI International (RTI). RTI is an independent, nonprofit research organization with experts in a variety of health care design, implementation and evaluation areas. Point of Care Partners, a management consulting firm, is serving as an expert advisor to the project. After six months of running the Fast PATH pilot initiative, RTI will evaluate the improvements to the patient-provider experience.
Alex Cowell, PhD, the RTI Engagement Leader said, “RTI is honored to serve as the independent evaluator to AHIP on a critical topic that affects patients and providers in support of higher quality and more efficient care delivery.” AHIP will use the results to work with doctors, hospitals, care providers, and other stakeholders on the development of interoperability and electronic prior authorization.
The goal is to offer a voluntary approach that is scalable and can be highly integrated with existing electronic health records systems. The Fast PATH initiative is another example of health insurance providers, doctors, and health information technology vendors working together for the betterment of patient care.
AHIP is the national association whose members provide coverage for health care and related services to hundreds of millions of Americans every day. Through these offerings, we improve and protect the health and financial security of consumers, families, businesses, communities and the nation. We are committed to market-based solutions and public-private partnerships that improve affordability, value, access, and well-being for consumers. Visit www.ahip.org for more information.