“Bringing pre-authorization to the point of service” reduces the burden on responders, notes a Regence executive.

Regency– a Blue Cross Blue Shield Association plan offering commercial, exchange, and Medicare Advantage (MA) plans in Idaho, Oregon, Utah, and Washington – launched a partnership with the ACO MultiCare to expedite prior authorization (PA) using the FHIR PA support standard.

The new standard “will provide an interoperable method for providers to submit prior authorization requests directly from point-of-care electronic health records,” Régence said in its Press release.

In the press release, Regence VP CTO Kirk Anderson states, “Pre-authorization at the point of care reduces the burden on healthcare systems managing patient data and promotes timely, evidence-based care and a more seamless experience for our members.”

AVP of MultiCare for population health and value-based care, Anna Tayloradds, “Integrating pre-authorization into our native EHR system is a game-changer… Not only will we alleviate the administrative complexity of healthcare, but the ability to receive transparent and actionable data at the point of care accelerates the delivery of care and increases compliance.”

PA Automation

Other health plans are automate the PA process. But Regence reports it’s the first health plan to do so using an FHIR application programming interface, or API, which “will enable faster determinations, reduced administrative overhead and costs, and better outcomes.” for patients”.

Automation of APs is one of the many operational improvements possible by FHIR, the definition including APIs. Two others include API-enabled patient data access and vendor directory standards, required by CMS Final Interoperability and Patient Access Rule. Payers offering MA, Medicaid or CHIP plans were required to comply with the provider directory rule beginning in July 2021.

And while X-enabled APs aren’t needed yet, CMS’ Interoperability and prior authorization rule was proposed in December 2020 but is not yet final. The Regence-MultiCare implementation reflects stakeholder understanding that FHIR-driven APIs are a key tool in making meaningful digital transformation in healthcare a reality.

PA under fire

Health plans use PA to manage the delivery of health services. Ideally, PA prevents misuse and promotes appropriate, evidence-based care. Providers and patients, however, see the real intent of PA as cost control that restricts access to needed services. Suppliers place the cumbersome PA process, which often requires dedicated staff to manage, as a key contributor to pandemic-aggravated burnout.

Congress agrees. In September, the House passed the An Act to improve rapid access to care for seniors, which requires MA Plans to report their AP utilization rates to the CMS, including resulting approvals and denials. The bill, also supported by the Senate, requires HHS to implement a “real-time” PA decision-making process facilitated by automation.

And while it only applies to MA plans, the bill — combined with CMS’s proposed interoperability rule — would create a pathway to the advancements in PA that stakeholders are calling for.

Laura Beerman is a staff writer for HealthLeaders.