“Prior authorization has been used for decades and yet significant operational challenges still exist,” said April Todd, Senior Vice President, CAQH. “This white paper outlines how we got to where we are today and offers a roadmap for collaborative solutions.”
Health plans require prior authorization for surgeries, diagnostic tests, procedures, medications, and various other healthcare services as a way to improve the quality of care and manage healthcare spending.
According to the 2018 CAQH Index, the number of prior authorizations has increased by 14 percent over the prior year and, although a federally mandated standard for automating part of the prior authorization process has existed for more than a decade, only 12 percent of prior authorizations are conducted using that standard.
The report highlights six factors that have slowed end-to-end automation:
The need for consistency in data content
Lack of federally mandated standards for attachments and clinical documentation
Lack of integration between clinical and administrative systems
Limited availability of vendor products that readily support the standard transaction
State requirements for manual intervention
Lack of provider awareness
Today, the Department of Health and Human Services, federal and state policymakers, provider and health plan associations, industry coalitions, and private sector organizations are all motivated to resolve the administrative burden associated with prior authorization. This creates an unprecedented opportunity to find alignment and implement solutions.
CAQH CORE has developed Phase IV and V Prior Authorization Operating Rules to establish common data and infrastructure requirements, and is testing new operating rules to support existing and emerging standards. This white paper highlights how these operating rules represent a significant opportunity to improve prior authorizations.
“The challenges providers, plans, and patients are experiencing with prior authorization have developed over decades,” continued Todd. “With broad collaboration and alignment, we can move towards a more automated, streamlined process.”
Industry-led, CAQH CORE was formed to drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability, and align administrative and clinical activities among providers, payers, and consumers. CAQH CORE Participating Organizations represent more than 75 percent of insured Americans, including health plans, healthcare providers, vendors, government entities, and standard setting organizations. Five phases of CAQH CORE Operating Rules and Certification Test Suites have been issued to date. For more information, visit www.caqhcore.org.