By Erik Yedwab, Vice President, Product Management at NantHealth |
The core purpose of prior authorization is to ensure that the treatment being prescribed for the patient is within recognized guidelines or standard of care for the specific diagnosis. The faster and more accurate key decision makers in the healthcare industry can make the prior authorization process, the quicker and more appropriately a patient can be treated, which translates to fewer treatment delays and better and timely quality of care.
Prior authorization is a major component of expensive therapeutics or a variety of procedures in healthcare. Back in the 1970s and 1980s, a healthcare provider prescribed treatment, submitted a claim to the health plan and received reimbursement. Now in present time, an additional step in the cycle requires the provider to get authorization for the treatment before the treatment even begins. Many health plans typically have a list of standard questions that the provider must answer, and in the absence of technology, fax to the health plan. Once the health plan receives the fax, the treatment plan typically undergoes a lengthy, manual review for approval. In many cases, the health plan needs clarification on some of the responses included in the request, which can add days or weeks to the decision timeframe as the provider and health plan communicate back and forth. This manual process not only leads to common errors and miscommunication, but a substantial delay in treatment.
When a patient needs treatment, the health plan should not be a hindrance to receiving efficient and timely care. Often, the prior authorization process required by health insurance companies can be tedious and time-consuming – leading to treatment delays. To help relieve the burden of prior authorization, many health plans are turning to technology to improve the historically drawn-out process.
For instance, treatment decisions for complex diseases such as cancer, often entail considering hundreds or even thousands of factors about the patient – from tumor characteristics to biomarkers and more. A study published in the JCO Clinical Cancer Informatics notes that the human brain can assess up to five variables per decision. So that begs the questions, how can we expect providers to make well-informed treatment decisions when they cannot possibly evaluate every variable; and how can we expect health plans to approve treatment without adequate knowledge of the suitability of the treatment plan?
On a similar front, patients diagnosed with autoimmune conditions often experience painful, life-challenging symptoms. In these cases, providers are trying to alleviate the patient’s pain as quickly as possible. Efficient approval from the health plan for access to the right medications is crucial in getting this done.
Technology can help enable better, more efficient patient care from the start. Web-based platforms like Eviti Connect can aggregate an almost infinite number of variables into a single point to narrow treatment options to the most relevant possibilities for an individual patient. When a provider presents a treatment option to their patient, both the provider and the patient need assurance that the health plan will reimburse the provider for the treatment. Technology-enabled prior authorization can allow an automatic review of the provider-recommended treatment compared with evidence-based standards of care to ensure that the treatment is appropriate for the individual patient, and therefore appropriate for reimbursement by the health plan. Additionally, technology allows heath plans to scale prior authorization programs to account for medical policy, formulary, and preferences.
Platforms that digitally and automatically compare the prescribed treatment with the patient’s diagnosis through a quick online prior authorization submission helps both providers and health plans ensure efficient, appropriate care for the patient. While manual processes are in so many cases the norm – digitally transforming key pieces of the healthcare cycle can be the key to offering patients the individualized, streamlined, and top care that they need and deserve.
About The Author
Erik Yedwab, ASA, MAAA, is VP of Product Management for NantHealth Eviti. He joined the Eviti team in 2007 prior to the acquisition by NantHealth and has been focused on expanding the company’s products and services. Erik has over 20 years of experience in healthcare data management, technology development, and actuarial analysis and support. He is a graduate of Richard Stockton College of New Jersey and has been designated as an Associate of the Society of Actuaries.