Blue Cross Blue Shield of MA Eliminates More Prior Authorizations

Blue Cross Blue Shield of Massachusetts (“Blue Cross”) joined other payers in eradicating prior authorizations for certain services as part of an effort to accelerate members’ access to care and reduce provider burden.

Between August and November of 2023, three major payers reduced their prior authorization policies: Blue Cross, Cigna, and UnitedHealthcare.

The latest of the three to announce a prior authorization reduction, Blue Cross eradicated 14,000 home healthcare-related prior authorizations for its commercial health plan members.

Practically, the new policy will affect prior authorizations for physical therapy, occupational therapy, and home visits from home health aides, nurses, and social workers. It will go into effect on January 1, 2024.

The new policy’s goal is two-fold, Sandhya Rao, MD, chief medical officer at Blue Cross, explained to HealthPayerIntelligence in an emailed interview.

First, eradicating prior authorizations for home care will decrease the resource strain on over-populated hospitals. Faster discharges may mean more available space for these health systems. With only a little more than 75 percent of US inpatient beds occupied in November 2023, fast discharges are crucial.

“We know from our clinical partners that local hospitals are experiencing a capacity crunch, so we’re doing what we can to help,” Rao shared.

Moreover, patients will see fewer delays in the transition from the hospital to the home. Many patients are more comfortable in the home setting and prefer to recuperate near their families, according to a study published in the Journal of the American Geriatrics Society. For this population, home care may improve their patient experience as well as their outcomes.

Blue Cross’s clinical partners played a significant role in driving this policy, Rao told HealthPayerIntelligence. Ideally, the lower rate of prior authorizations will reduce the administrative burden on provider partners.

“We value our partnership with our clinical partners and communicate with them about any changes. This is a way for us to work with them to ease administrative burden and make the transition from hospital to home smoother from end to end,” Rao added. “This should help streamline care delivery, allowing hospitals to discharge Blue Cross members more efficiently.”

The decision was part of Blue Cross’s overarching strategy to improve the prior authorization process.

The payer had already taken steps to ensure that 98 percent of its claims do not require prior authorizations. Prior to this announcement, the payer had eradicated prior authorizations for Type 1 diabetes supplies, continuous glucose monitoring devices, outpatient mental health treatment, and transfers between emergency departments and inpatient mental health stays.

Additionally, Blue Cross implemented automated prior authorizations as part of the Fast Pass proof-of-concept pilot. Automating this process reduced prior authorization approval time from around nine days to less than a day.

Rao indicated that the payer is continuously looking for ways to reduce the prior authorization burden, evaluating which services and devices benefit the most from implementing prior authorizations.

Although there are many benefits to reducing prior authorizations, Rao maintained that it is still useful.

“We know that prior authorization can be cumbersome in some instances, but it’s also an important tool for ensuring that the expected benefits of services, treatments, and medications outweigh the potential risks and complications and contribute to improved health outcomes and lower costs for our members,” Rao explained.

Payers use prior authorizations, sometimes combined with a step therapy approach, to direct patients toward lower-cost treatments that may have similar effects, evaluate medical necessity, and assess whether the procedure, prescription, or device is covered. However, providers have argued that the process sets up obstacles to care, especially for patients with time-sensitive conditions.

“We’ll continue to work toward streamlining the process even further, and would welcome guidance from government entities,” said Rao.

In 2023, CMS finalized a rule related to prior authorization processes in Medicare Advantage plans. The rule stated that plans must reassess their utilization management policies each year. Also, denials must be reviewed by a healthcare professional with relevant experience.

Other payers have implemented alternative approval processes. For example, UnitedHealthcare introduced its national Gold Card program for eligible provider groups, which will go into effect in 2024. Gold carding allows providers with a proven record of high quality care to bypass prior authorizations. However, the process has seen mixed results.

Health Care Service Corporation (HCSC) has incorporated articficial and augented intelligence tools to make prior authorization processing 1,400 times faster. Other payers have cut back on prior authorizations for services including cataract surgery and gastrointestinal endoscopy.