Health systems test real-time prior auths through Epic

Four health systems are getting closer to real-time prior authorizations with a new feature from Epic.

Announced ahead of the Epic Systems Users Group Meeting, the health IT giant said Ochsner Health, Froedtert ThedaCare, Denver Health and Summit Health are now using an application programming interface to check prior authorization requirements automatically for major insurers, including UnitedHealthcare, Aetna and Network Health.

Epic dubbed the new API the Coverage Requirements Discovery, or CRD, which aggregates prior authorization requirements within the EHR system at the time a clinician places an order or a staff member schedules an appointment.

The company said the API will eliminate the need for manual work, such as phone calls, faxes and re-entering information into separate insurance portals -- all of which have been major pain points in the prior authorization process for providers.

"At Ochsner Health, we're excited to implement the Prior Authorization API, which transforms a traditionally manual, time-consuming process into a streamlined experience for our care teams," Melissa Woods, Ochsner Health’s assistant vice president of revenue cycle and financial clearance, said in a statement earlier today.

The API will cut administrative burden and increase efficiency while mitigating delays in patient care, Woods added.

The CRD API also meets a requirement in a new federal interoperability rule mandating the use of APIs for the prior authorization process, Epic said.

Most Medicare Advantage, Medicaid and Affordable Care Act Marketplace insurers will need to use standardized APIs from Health Level Seven International, which leverage the Fast Healthcare Interoperability Resources technical standard. The impacted payers must implement the APIs by January 1, 2027.

Currently, the APIs, which function as digital pipelines for electronic data exchange between parties, are in a testing and implementation phase. The Centers for Medicare and Medicaid Services is actively working with 29 early adopters of the APIs, including leading EHR companies such as Epic, Oracle Health and athenahealth. Froedtert ThedaCare and Ochsner Health are also part of the first group to pilot the APIs.

The four health systems are now live with the prior authorization API from Epic five months ahead of the regulatory deadline, Epic stated. Sixteen more payers are also currently testing it, according to the announcement.

These partnerships make real-time prior authorizations possible, suggested Imran Andrabi, president and CEO of Froedtert ThedaCare. The API allows patients and clinicians to focus on needed care, he continued.

Collaboration through the CMS' early adopter demonstration of the required APIs has been critical to enabling faster, more efficient prior authorizations, according to Amy Trainor,  system vice president and chief information officer at Ochsner Health.

Trainor said in a previous interview with RevCycle Management that the demonstration supports real-time communication with other stakeholders in the prior authorization process in a single channel. This has addressed one of the major obstacles of innovation for this process: finding the right person to speak to on the other end.

"I feel like this is why it's working so much better than it had in the past. It's not that my team or the payer team didn't know how to create a FHIR API connection; it's that they didn't know who to talk to," she said.

The prior authorization process has been notoriously burdensome for payers and providers, prompting the CMS to home in on improvements through regulation. About 50 health insurers also took a pledge in partnership with the federal government to fix prior authorization requirements through 2027.

However, providers remain skeptical about the progress payers have touted with their pledge, saying they have yet to feel the on-the-ground effects of the efforts, including reducing the number of services subject to the requirements and enhancing communications around determinations.

The upcoming CMS requirements provide the accountability needed to make real progress with prior authorizations, they say.

Jacqueline LaPointe is an Executive Editor at Xtelligent Healthcare Media, covering revenue cycle management, healthcare payers, health policy and health IT since 2016.