Prior authorization automation hinges on human connection
Healthcare is rapidly automating the prior authorization process, but Ochsner Health has found that a new initiative connecting payers and providers is making progress tangible.
"People, process, technology" is a mantra healthcare IT leaders have repeated for decades. But when it comes to electronic prior authorization, Ochsner Health is discovering that getting the first two right matters far more than the third, and a new government-led initiative is finally making those human connections possible.
The initiative, part of the Centers for Medicare and Medicaid Services' Health Tech Ecosystem, has organizations implementing upcoming electronic prior authorization workflows before the Jan. 1, 2027, deadline to ensure they work. Specifically, they are testing application programming interfaces that support standard electronic data exchange between payers and providers.
But killing the clipboard, as CMS Administrator Mehmet Oz puts it, will take more than APIs. For Ochsner's Amy Trainor, system vice president and chief information officer, it's about the connections made among early adopters.
"The ability to collaborate in that space has really, really driven conversations that probably wouldn't have happened over the years because the right people wouldn't know who to connect with," she told RevCycle Management.
Trainor said the initiative is succeeding where previous attempts have failed by creating communication channels and accountability frameworks that foster collaboration.
Giving everyone a seat at the table
Payers and providers have been coming to the table for decades, but that proverbial table has been one for negotiating contracts, not necessarily getting on the same page. Even when these stakeholders do come together, there has been deep, persistent friction.
One in five providers in a new report from Zelis cited friction in payer relationships and processes as their organizations' top challenges this year. Nearly the same percentage (17%) of payers said the same. Researchers found that administrative complexity is driving this friction, but 37% of payers and 42% of providers cited prior authorization delays as a top source as well.
Payers and providers in the report overwhelmingly agree there's more friction than there should be, yet fewer than half of payers and providers say they actually collaborate on cost and quality data. This is even as both analyze the same exact claims.
Trainor has witnessed a similar dynamic play out with trying to automate the prior authorization process.
"Like any good tech project, relationship building and understanding problems that we're trying to solve together are probably the biggest problems," she said. "A lot of times, there was a lot of misunderstanding of what our goals were."
"What were the provider's goals?" she posited. "What were the insurance company's goals? How do we come together for a singular goal?"
The CMS initiative has created a sounding board for payers and providers, as well as EHR and health IT developers, to answer those questions and test solutions.
Trainor described the collaboration via a Slack channel, which allows a participating organization to get its ideas in front of others and see who wants to collaborate. This has not only supported the implementation of the upcoming APIs but also accelerated improvements to the process, enabling real-time communication to fine-tune newfound data-sharing capabilities.
"The initiative has gained a lot of momentum because we're putting all the people that are trying to solve the same problems together via Slack channel and really allowing them to innovate and work together quickly," Trainor said.
Creating accountability for prior auth progress
The healthcare industry has been talking about data standards for well over two decades now. Even the technological infrastructure the federal government has tapped to facilitate electronic prior authorizations -- Health Level Seven International's Fast Healthcare Interoperability Resources -- has existed for over a decade.
But the industry lacked one key factor for implementing data standards and streamlining prior authorizations: a reason to do so.
"The piece that I find to be moving it faster is the accountability," Trainor said. "So, I think while the technology may have existed for a lot of this, there weren't any mandates or requirements for people to participate. It was almost like doing it for the good of being good."
While our connection to Medicare might be different than our connection to Aetna, the path, the road that we get there and the tool that we use is the same.
Amy Trainor, SVP & CIO, Ochsner Health
But there's a lot of good to be done in the healthcare industry, and not all provider organizations have the resources to spare for prior authorization automation, even though it could improve access to care for their patients.
"It's a big investment from us from a resource perspective," Trainor explained. "We work in nonprofit healthcare, so the priorities are always going to be what are the tools that are facing our physicians, clinicians and staff? How do we make those right investments in our network and our infrastructure?"
Ochsner considers itself to be an innovator in the health tech space, according to Trainor, so the health system has been investing in prior authorization improvements over the past four years. However, this innovation has happened in a vacuum.
The health system has seen success with these investments; about 30% of the organization's Humana's prior authorizations are electronically done, 28% of UnitedHealthcare's and 18% of Louisiana Blue's.
Much of this success was facilitated by Ochsner's EHR system, Epic, which has a payer platform that uses FHIR to support interoperable, electronic data exchange for prior authorizations.
Scaling success in this space has been a challenge for providers. Payers may not be on the same platforms, nor, as Trainor recently realized, are the third parties payers tap to perform prior authorization functions .
New regulations from the CMS will change that, though, covering 50-60% of Ochsner's prior authorizations right off the bat, according to Trainor. The regulations will require even those third-party vendors to use HL7's FHIR to connect provider and payer platforms across four APIs by the start of next year.
"CMS stance is: This is how we're going to talk to each other," Trainor stated. "So, while our connection to Medicare might be different than our connection to Aetna, the path, the road that we get there and the tool that we use is the same. We're not starting from scratch every time."
What success looks like
Trainor hopes that turning on the APIs will push electronic adoption rates into the 80s.
"To me, there's an 80-20 rule," she said. "About 80% of our [prior authorizations] should be automated. Yes, there's going to be a time when it needs human intervention, maybe a piece of paper, but I hope for that time to be getting a lot smaller."
But ultimately, the goal for Ochsner is to get prior authorizations completed faster. In general, electronic prior authorizations already save providers an average of 14 minutes per transaction, according to the CAQH Index report.
Artificial intelligence could make them even faster, according to Trainor. As healthcare stakeholders become more comfortable with electronic transactions, agentic AI could help streamline the process by identifying the relevant information and packaging it for transmission to the payer.
"So that by the time we get to the electronic authorization, we feel really good about the product we're delivering," Trainor elaborated.
Payers and providers alike are rapidly applying AI to this notoriously burdensome process, making it one of the biggest use cases for AI in healthcare right now. The industry is still in the early stages of adoption and operationalization, working out kinks that have raised concerns about AI's role in denying care.
But Trainor believes this tech-enabled approach supports the people and processes behind care delivery.
"I always reflect on those diagnoses that you don't want to hear and how we could decrease the amount of waiting time for those folks in any aspect to put their minds at ease," Trainor said. "You have a cancer diagnosis; we're going to put your port in tomorrow. Does that work for you? It just feels different and more right."
Jacqueline LaPointe is an Executive Editor at Xtelligent Healthcare Media, covering revenue cycle management, healthcare payers, health policy and health IT since 2016.
