Prior-Authorization Woes? These Tools May Change the Game

Alok S. Patel, MD


May 22, 2023

This transcript has been edited for clarity.

Sometimes when I want to be deliberately annoyed, I go on Twitter and search "prior authorization," and I read stories about how insurance companies need to be told why patients need albuterol, insulin, epi pens, imaging, cancer screenings, and more.

Here's the thing: Rants alone are not going to expedite the prior-authorization process, and we really need to fix this glitch in delivering patient care. Maybe artificial intelligence is the answer. It also kind of feels like the answer to everything right now.

First, let's outline the problem. Here are some numbers directly from the American Medical Association:

  • About 80% of physicians say prior authorizations have led to treatment abandonment.

  • 33% say they've caused a serious adverse event.

  • About 90% of physicians say prior authorizations negatively impact patient outcomes.

Here's another number: A 2021 Kaiser Family Foundation Issue Brief stated that 99% of Medicare Advantage enrollees are in plans that require prior authorizations for some services, including mental health services.

At the state level, there is some advocacy and pushback. Some states have gold-card laws exempting certain physicians with a good track record over the past year from having to deal with prior authorizations. Michigan passed a law supporting transparency automation in the process. New York prohibits prior authorizations for inpatient mental health care for minors. California recently introduced and passed Senate Bill SB 598, which removes prior authorizations for a year — with some asterisks.

All this advocacy is surrounding the use of prior authorizations. Guess what? They still exist and they're still cumbersome. Maybe modern tech can help because technology should be in favor of patients, not insurers.

A recent ProPublica article reported on Cigna's PXDX system, which is part of its review process and enabled doctors to instantly reject claims without actually reviewing patient data. In the article, a former Cigna employee reported that the system was so efficient that it could take 10 seconds to reject 50 claims.

There's already support for programs such as Fast PATH, or Fast Prior Authorization Technology Highway, which are basically electronic ways around the cumbersome manual process. Right now, prior authorizations require a large amount of data entry, phone calls, and even faxes. Why are we still using fax machines, by the way?

Here's a huge announcement from Google that has people excited, including me. Google recently announced the Claims Acceleration Suite, which is basically a set of AI tools that will help streamline this entire process, from determining whether a prior authorization is even needed, to collecting data, to helping with workflow on the insurer's side.

The backbone of the Claims Acceleration Suite is the Google Cloud tool called Claims Data Activator, which may make the prior-authorization process much faster than the current average of 10 days, according to the Centers for Medicare & Medicaid Services.

A couple other technology platforms embedded into this process are Myndshft and Pega — which are awesome names, by the way. Myndshft's software integrates with the EMR, checks patients' insurance benefits, immediately determines whether a prior authorization is even needed, and then autopopulates forms with patient demographics and pertinent medical information. Health information then gets extracted and stored as structured data. Pega's platform can make the review process for insurers more efficient by using AI to help with decision-making and automation of workflow.

Obviously, one aspect that's missing is accountability and making sure that people use these tools responsibly. Let's be real — if this technology is not in the best interest of insurance companies, there might be some pushback. For example, if you look up who opposes legislation such as SB 598 in California, you'll see it's usually insurance providers or affiliated groups.

Maintain the advocacy because it works. For example, UnitedHealthcare recently announced that they're getting rid of 20% of prior authorizations. One can imagine that this is at least partially due to all of the testimonials from people like us, who actually take care of patients.

This isn't just a video about how much I dislike prior authorizations and loathe doing them because of the increase in workload and stress, the delays in patient care, and the phone calls I get from patients who are panicking because they can't get their medications or other treatments in time because the insurance company is denying them. No, no, no.

This is about solutions. Personally, I like the direction that Google is headed in because it may increase efficiency in the prior-authorization process and transparency and accountability, which is something that our healthcare system needs way more of.

What do you think? Let me know in the comments section.

Alok S. Patel, MD, is a pediatric hospitalist, television producer, media contributor, and digital health enthusiast. He splits his time between New York City and San Francisco, as he is on faculty at Columbia University/Morgan Stanley Children's Hospital and UCSF Benioff Children's Hospital. He hosts The Hospitalist Retort video blog on Medscape.

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