As we navigate the changing landscape of Medicaid enrollment and revenue, it is vital to focus on optimizing your medical management operations, with particular attention to the utilization management (UM) team. The UM team plays a critical role in managing healthcare costs while maintaining the quality of care provided to members. As we anticipate a significant loss of Medicaid membership during the unwinding period, optimizing healthcare resource utilization becomes even more crucial to ensure your financial stability.
One area of focus is the prior authorization (PA) process, which can pose challenges for managed care organizations (MCOs) and healthcare providers alike. While PA serves as a cost control measure, it can also create administrative burdens and delays that impact the delivery of timely and efficient care. To address these challenges and enhance care delivery, we need to streamline the PA process.
1. Stay Ahead with Program Requirements & Regulations
To drive better outcomes and efficiencies, MCOs must stay on top of the specific state and federal requirements governing their operations. By closely adhering to guidelines set by accreditation bodies like URAC and NCQA, MCOs can ensure compliance and meet accreditation standards, as well as state and federal mandates. A deep understanding of how prior authorization impacts their organization empowers leaders to make informed decisions, optimizing the process while maintaining regulatory compliance.
2. Embrace Technology for Prior Authorization Support
The days of large teams navigating cumbersome manual workflows for prior authorization are behind us. MCOs need to assess their utilization and claims operations, aiming to identify areas for improvement, streamline processes through automation, and expedite the identification and resolution of gaps in care. Investing in advanced technology, such as artificial intelligence applications, can significantly reduce manual errors and automate the end-to-end review process. Upgrading to modern systems and leveraging AI-driven solutions streamlines prior authorization, minimizing delays and improving accuracy. For example, Blue Cross Blue Shield of Massachusetts reported that after embedding AI into its web-portal technology, 88 percent of its PA submissions were processed automatically in real-time.1 This investment not only enhances operational efficiency but also provides valuable data-driven reporting to drive continuous improvement.
3. Create a Seamless Submission Process
In an ever-evolving landscape, it’s essential to adapt the PA process to meet changing requirements. The proposed rule by CMS on Advancing Interoperability and Improving Prior Authorization Processes introduces new guidelines to increase efficiency in PA, reduce burden, and improve patient access to electronic health information. By implementing clear process flows and ensuring easy submission of authorization requests, MCOs can streamline the PA process. Adhering to the proposed rule’s shortened timeframes for decision notices enables better management of auto approvals and direct submissions to claims or billing systems.2 This approach, coupled with reviewing medical necessity criteria pre-service, ensures effective care delivery without overutilization.
4. Empower Providers with Streamlined Strategies
To align with the industry’s shifting focus towards member-centric care, MCOs are exploring strategies to eliminate prior authorization for non-urgent planned services and support providers. Leading MCOs such as UnitedHealthcare, Aetna, and Cigna have already taken proactive steps by announcing their plans to revamp their PA programs ahead of the new CMS PA-focused proposed rule. For example, United is eliminating 20% of current prior authorization as of Q3 2023.3
The key to empowering providers lies in continually reviewing current processes. MCOs must identify areas of opportunity and eliminate unnecessary efforts. To eliminate the artificial barrier to access created by the PA review process, MCOs can automate and reframe the case review as a retrospective audit function. This strategic shift ensures ongoing compliance with requirements while leveraging data to monitor appropriateness, effectiveness, timing, and setting, ultimately enabling the evaluation of trends for continuous process refinement. By leveraging data-driven insights, MCOs can identify providers who consistently adhere to the PA process without any issues and reward their efforts. Strategic changes like modifying the submission routes or timeframes for review can significantly support providers’ practices. Additionally, grouping providers based on quality and quantity can expedite manual efforts required during the PA process. By prioritizing quality metrics and fostering strong partnerships with providers, MCOs can drive better care delivery while minimizing the reliance on PA.
5. Improve Engagement with Effective Communication
Strong communication and engagement are vital for a streamlined prior authorization process. Both providers and members need to understand the PA process and its impact on patient care. MCOs should provide comprehensive training and education to providers, emphasizing the importance of timely PA request submission. Clear communication channels and regular updates on PA request statuses are crucial for building trust and transparency. Similarly, educating members about the PA process, specific requirements for medications or treatments, and timely updates on their requests empower them to actively participate in their own care journey.
Navigating the Future of Prior Authorization in Managed Care
As the healthcare industry continues to evolve, prior authorization processes will also undergo transformation. By implementing these five strategies, MCOs can navigate the challenges and achieve a streamlined PA process. Staying informed, leveraging technology, creating seamless workflows, empowering providers, and prioritizing effective communication will optimize care delivery, minimize delays, and improve member and provider satisfaction.
At Clearlink, we specialize in helping plans navigate the complexities of PA and stay ahead of industry changes. Our end-to-end consulting services and innovative solutions can empower payers to enhance their PA processes and achieve higher levels of member and provider satisfaction.
Here’s what Kristin Poth, AVP at Johns Hopkins Health Care (JHHC) had to say about how we supported their prior authorization program optimization:
“Clearlink brought our vision to life, developing data-driven reports that support the review of services in our prior authorization program and established a dedicated committee to review best practices in prior authorization. With their support, we are prepared for the future, ensuring high-quality, cost-effective care for our members while minimizing provider and member abrasion.”
Together, we can navigate the evolving landscape and shape the future of managed care. Schedule a consultation with our team today to discover how Clearlink can be your trusted partner in evaluating and streamlining your prior authorization process and accelerating your success.
- RevCycleIntelligence, “From AI to Regulation, Making Progress with the Prior Authorization Process”
- Kaiser Family Foundation, “CMS Prior Authorization Proposal Aims to Streamline the Process and Improve Transparency”
- Benefits Pro, “UnitedHealthcare, Cigna, Aetna revamping prior authorization ahead of CMS rule”