AHA: Electronic Prior Authorization Implementation Requires Testing

The American Hospital Association (AHA) has expressed support for electronic prior authorization processes but urged the Office of the National Coordinator for Health Information Technology (ONC) to fully develop and adequately test any solution before requiring health systems to comply with a new regulation.

In response to a request for information on electronic prior authorization standards, implementation specifications, and certification criteria, AHA submitted comments to ONC regarding the best way to approach automating the prior authorization process.

While health plans aim to validate the efficacy and safety of patient care through prior authorizations, the requirement can create delays in care for patients and increase administrative burden and burnout for providers.

Establishing a standardized electronic prior authorization process may help expedite care delivery and preserve resources. However, AHA has asked ONC to work with CMS to ensure that automating prior authorization will not exacerbate the current workload problems health systems are facing.

“In order to effectively update and create standard transactions without unduly burdening healthcare payment processes, regulators should approach potential changes judiciously,” AHA wrote. “Any substantial change in the technology and/or standards used in healthcare information exchange should be sufficiently tested to ensure functionality, analyzed to establish projected return on investment, and incorporated according to an appropriate glide path to minimize systematic disruption.”

The trade organization said it supports an end-to-end automated prior authorization process that integrates with clinician EHR workflow. Health plans vary on which methods of prior authorization requests and documents they accept—some plans accept electronic information while most plans and providers communicate via fax or telephone.

Electronic submission typically requires providers to use proprietary plan portals, which can be a lengthy process and reduces administrative efficiencies, AHA said. Transferring EHR information into payer portals can also lead to entry errors and subsequent denials.

Implementing an end-to-end automated process that incorporates EHR data would help clinicians overcome this barrier, the letter stated. Additionally, using EHR technology could help increase real-time access to patient information for clinicians during treatment planning.

AHA urged ONC to fully develop and test the proposed implementation guides for electronic prior authorization processes before rolling it out to the entire industry.

“This process should include careful consideration as to the transaction’s scalability, privacy, and necessity of access to the transmitted health information and ability to complete administrative tasks in a real-world setting, rather than a controlled environment such as an HL7 Connectathon,” AHA recommended.

A real-world analysis would also help ensure consistency across application programming interface (API) usage. According to AHA, streamlining API usage would facilitate data exchange between patients and providers while reducing burden and improving patient care.

The letter also asked ONC to standardize a method of attaching clinical data to claims. Although there is an apparent need for this among health systems and HIPAA and the Affordable Care Act have required healthcare attachment standards, AHA said that attachment transactions have yet to be standardized via regulation.

Finally, AHA noted that leaders should implement additional prior authorization reform beyond automation to improve patient outcomes. For example, health plans should issue prior authorization determinations with 72 hours for standard requests and 24 hours for urgent matters.

Additionally, officials should increase oversight to ensure that health plans are not denying medically appropriate care and enhance control over prior authorization applications to ensure that they only use it for high-cost or over-utilized services. Plans should also be required to process prior authorizations at all times instead of just during standard business hours to prevent patient care delays.

Over 90 percent of physicians reported that prior authorizations delayed patient access to necessary care, according to data from the American Medical Association (AHA). Care delays may push patients to abandon treatment altogether, exacerbating their health conditions.

Providers face significant administrative and financial burden from prior authorization requirements as well. AHA referenced a health system that spends $11 million per year to comply with prior authorization requirements.

In 2021, medical group practices cited prior authorization as the top regulatory burden, ranking above COVID-19 mandates.