How a Better Prior Authorization Process is Rising from FHIR

Setting prior authorizations on FHIR

Prior authorizations are one of the most burdensome tasks in healthcare. According to the American Medical Association (AMA), physicians complete an average of 41 prior authorization requests each week, spending about two business days on the process alone. About 40 percent of physicians also have staff who exclusively work on prior authorizations.

But more than that, most physicians say prior authorizations delay access to necessary care as they wait on payers to authorize services. Over a third of physicians also blame prior authorizations for severe adverse events among some of their patients.

Despite staunch criticism from clinicians, prior authorizations are part of healthcare’s solution to its spending problem. Payers employ prior authorizations to ensure members are receiving absolutely necessary care without the added cost. Prior authorizations, for example, can help patients bypass unnecessary or expensive treatments when a lower-cost, equally effective option is available.

To overcome the challenges of prior authorizations, MCC and Regence have tapped FHIR to streamline the process and get providers and patients an answer before delays threaten access to care.

HL7 FHIR, according to the ONC, defines how health data can be exchanged between IT systems regardless of how the data is stored in those systems. This means anyone who needs to access clinical or administrative data can do so securely in a “lightweight, real-time fashion using modern internet technologies and standards.”

Applying an interoperable data standard to the prior authorization has cut down the work MCC and Regence do to complete the process. Using FHIR, for example, MCC’s prior authorization team can now click a button within the EHR system to start a request for service pre-approval and have the necessary data populate.

“By utilizing this technology, it enables us not only to exchange data in a one-to-many fashion, from a platform perspective, it also enables us to reduce all of the little pieces in between, like passwords and clicks and having to pull the data that you need out of the record,” said Anna Taylor, MCC’s associate vice president of Population Health and Value-Based Care.

“This solution pulls it itself and then we're just doing what you would call a high-reliable crosscheck and it enables all of that to happen in a matter of two minutes.”

With a quick verification of the pre-populated data, the request then goes to Regence’s team, which receives clinical decision support information in a standard format.

“On our side, as a payer, a lot of manual work comes into this process through sorting all of that clinical data, and when it's in a different format every time and through a different channel, that's where a lot of the delay comes into play,” Anderson explained.

“The beauty of the solution we have put into production with MCC is that we are automatically pulling the data that is required and no more. When it comes over to us, it comes over in a predictable, structured way.”

The FHIR-based prior authorization process is also cutting down the number of submissions from MCC by enabling near real-time responses from Regence on whether a pre-approval is even needed.

“If you look at all of the prior auth requests that come into us as a payer, 50 percent of the time, the answer to whether it is even required is no,” Anderson stated. “Now that we can give that immediate feedback to the provider, they can immediately move on to the next step in the process, which might be scheduling that particular procedure.”

Scaling a better prior authorization process

The HL7 FHIR Prior Authorization Support Standard is making the prior authorization process between MCC and Regence. However, MCC works with over 28 payer partners, each of which requires prior authorizations and has its own processes for submitting them.

“One of the most challenging aspects of prior authorizations is that our authorization team has to remember 28 different passwords, 28 different portals, 28 different processes,” said Taylor. “That complexity is something that doesn't have to exist.”

Electronic prior automation adoption has been steadily increasing, according to the latest CAQH Index, but the process is still one of the most manual compared to other medical administrative processes. Many providers still have to use the phone, mail, or fax to submit requests to some payers. However, partial electronic adoption is also to blame. Payers typically use their own electronic solutions and portals to manage prior authorizations, leading to the complexity MCC experiences every day with prior authorizations.

“We’ve been trying to solve some of healthcare’s key problems like prior authorization with proprietary solutions, meaning we could invest a lot to make something work, but it would only work for MultiCare,” Anderson stressed. “We would end up with dozens of different ways to solve the same problem, depending on which technology vendors we as payers and providers had chosen to adopt.”

The resources needed to manage those electronic solutions is also not sustainable for a health system, Taylor added.

“For every use case that you would need to exchange data with payers, whether it is safety measures, continuity of care, prior authorizations, claims, all of revenue cycle, that means that I have to build it 28 times. We can't afford to build the 20-plus use cases 28 times as a health system,” Taylor elaborated.

“Even if you are able to make it capital-investned, the monitoring of those solutions and babysitting the data and digital plumbing is not sustainable for a health system because our core business is caring for patients and the communities we serve. That is where we would like to focus the dollar that we receive in return for our services.”

The HL7 FHIR Prior Authorization Support Standard, on the other hand, is an open data standard, so it can scale to MCC’s other payer partners or Regence’s other provider partners. “It is nobody’s secret sauce,” Anderson said.

From trailblazers to common use

MCC and Regence are trailblazing the use of FHIR for prior authorizations, but they won’t be the only ones to leverage the data standard for a more streamlined process. CMS issued a proposed rule in December 2022 that, if finalized, would require implementation of an HL7 FHIR standard application programming interface (API) just like the one currently used by MCC and Regence.

“The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote health care data sharing to improve the care experience across providers, patients, and caregivers—helping us to address avoidable delays in patient care and achieve better health outcomes for all,” CMS Administrator Chiquita Brooks-LaSure said in a statement last month.

But it is thanks to organizations like MCC and Regence, which worked with HL7’s Da Vinci Project to prove that an FHIR-based prior authorization process works. The Da Vinci Project is a private sector initiative that leverages the FHIR platform to address the needs of value-based care.

“It's invaluable for them to be able to point to the work that has been done by Da Vinci because they know that they're not just inventing something in a rule and hoping that it will work. They are able to point to real-world implementations and also the result of iterative problem-solving and collaboration between these entities that they are now seeking to regulate,” said Anderson, who also serves as board chairman of Da Vinci.

With prior authorization problems coming to a head, it is likely payers and providers across the country will be tapping the same technology as MCC and Regence to improve the process. But for others to see the same results, Taylor advised greater collaboration among payers, providers, and their technology vendors.

“One opportunity is to ensure that your electronic health record is highly involved with the development that goes on in building a solution because, in a way, you are at the mercy of what they put in their APIs and make available,” Taylor said.

The other lesson Taylor learned from being the first to implement this type of electronic process is that “data today isn't always built for the logic tomorrow.”

“As medicine becomes more complex, so will our capabilities to have more flexibility in how data is presented and how it's plumbed between each other. In the data world, we call this the payload but in real life, this is the stuff people are entering into the electronic medical record. It's your name, it's your birthday. Sometimes, in the standards of the past, that data structure wasn't sophisticated enough to make these complicated conversations. So, because it's been built on past standards, that doesn't mean it can be in the new standards instantly.”

Getting all stakeholders on the same page will take time, especially as new data standards emerge. However, the future is bright for FHIR-based prior authorizations.

“It’s a common utility upon which the American healthcare system can innovate and deliver features and capabilities that help us get better care outcomes and stop spending so much money moving data back and forth in all these different ways,” Anderson stated.