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AHIP

Prior Authorization

Helping Patients Receive Safe, Effective, And Appropriate Care

Defining Prior Authorization

Prior authorization is one of the many tools health insurance providers use to promote safe, timely, evidence-based, affordable, and efficient care. Under the supervision of medical professionals, prior authorization can reduce inappropriate care by catching unsafe or low-value care and targeting where care may not be consistent with the latest clinical evidence – both of which can contribute to potential harm to patients and unnecessary costs.

The prior authorization process can be burdensome to providers, patients, and health plans alike, especially when working on an outdated, paper-based system. In 2018, stakeholders representing providers and insurers developed a Consensus Statement recommending opportunities to improve the prior authorization process. Increasing the adoption of electronic prior authorization was one of the major opportunities identified for improving prior authorization.

Fast PATH Initiative

Health insurance providers consistently seek ways to enhance the patient and provider experience. In January 2020, AHIP launched a new initiative called the Fast Prior Authorization Technology Highway (Fast PATH) better understand the impact of electronic prior authorization (ePA) on the prior authorization process. This initiative builds on key priorities for improvement identified in the Consensus Statement.

Six health insurance providers that collectively cover over 50 million Americans participated in the project, with Availity and Surescripts serving as the technology partners and Point of Care Partners serving as an expert advisor. RTI International conducted an independent analysis of the project, looking at prior authorization transaction data both before and after implementation of ePA processes and surveying providers on their experiences using ePA technology.

Fast PATH Key Findings

Faster Time to Patient Care

71% of providers who used the technology for most or all of their patients (referred to as experienced users) reported that patients received care faster after providers implemented electronic prior authorization

Faster Time to Decision

Median time between submitting a prior authorization request and receiving a decision from the health plan was more than three times faster, falling from 18.7 hours to 5.7 hours – a reduction of 69%.

Lower Provider Burden From Phone Calls and Faxes

Among experienced users, a majority of providers experienced less burden related to phone calls and faxes after implementation of electronic prior authorization:

  • 54% of experienced users reported fewer phone calls and 58% reported fewer faxes after implementation of electronic prior authorization
  • 62% of experienced users reported less time spent on phone calls and 63% reported less time spent on faxes after implementation of electronic prior authorization

Improved Information for Providers

60% of experienced users said electronic prior authorization made it easier to understand if prior authorization was required

Greatest Benefits for Experienced Users

The more frequently a provider used the technology solution, the bigger the benefit the provider experienced in reduced burden and ease of understanding prior authorization information.

Fast PATH Lessons Learned

Based on the findings that providers who are high users of the electronic prior authorization technology experience the greatest benefit, it is clear that to maximize the efficiencies of electronic prior authorization, strong provider adoption of the technology solution is critical.

To further realize the benefits of prior authorization, stakeholders should explore available pathways to increase provider adoption of ePA technology. These pathways could include a combination of: (1) increasing the availability of the technology to providers; and (2) increasing the use of the technology where it is already available by identifying and addressing challenges, such as provider readiness and training, workflow integration, and incentives for providers to use the technology.

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