Blog Mar 20, 2023

Reducing Administrative Burden with FHIR-enabled Prior Authorization

Authored By: Guninder Bhatia, Product Owner & Sr. Consultant (Interop & Data Mgmt.) and Ramganesh Subramanian, Asst. Vice President, Enterprise Data Strategy & Interoperability

Prior Authorizations are Still Burdensome

Prior Authorization (aka PA or prior auth) is one of the most challenging and complex financial processes in healthcare operations. It often requires manual intervention, that adds to administrative overhead payers and providers, impacting patients with delays in care, added financial stress, and confusion.

As a process for providers to receive an approval from a payer before the patient receives healthcare products or services, the goal or prior auth is to ensure that healthcare goods and services are medically necessary, appropriately covered by benefits, cost-effective, and free from fraud and abuse.

Unfortunately, prior authorizations are often still solicited via phone and fax as well as emails and web portal requests. And they typically require manual intervention, leading to host of untoward effects:

Lag time and inefficiencies between request and authorization decision
Treatment delays and clinical Impediments for patients care delivery
Adverse impact on the scheduling and appointment workflow
Negative patient experience and risk of delayed or cancelled treatment

While payers and providers have increased focus on streamlining and simplifying the prior authorization process, it continues to be burdensome and costly.

Why Change is Needed to Enhance Prior Authorizations Now

According to the 2021 CAQH Index report, the data bear out the need for electronic transactions purely from a cost savings perspective:

$391 billion is spent on administrative complexity in US healthcare
$42 billion of that (11%) is spent on administrative transactions tracked by the CAQH Index
Healthcare can save 48% ($20 billion) annually by transitioning to fully electronic transactions*1

Despite the cost-saving potential of an electronic transaction process, the manual process continues to be the preferred method for submitting requested patient records to health plans.

The pathway to adopting electronic or digital transactions like prior auth comes down to ensuring that the staff experience technology that is easy to use, reliable, consistent, and one that integrates with existing workflows is implemented. FHIR® (Fast Healthcare Interoperability Resources) offers a reliable, robust technology that can reinvent the PA process along with patient, staff, and clinician experiences.

Using FHIR to Improve the Prior Authorization Process

CMS intends to streamline the PA process using FHIR standards. This is also backed by the Office of National Coordinator for Health IT (ONC) that mandates the Certified Patient Health Records (PHR) vendors and EHR/ EMR vendors to incorporate FHIR standards into their products. Additionally, payers need to develop and upgrade their Prior Authorization process using FHIR technology.

FHIR technologies can enable bi-directional data exchange between a hospital or practice HER supporting the billing system that is used for patient management and payer systems. This process could be streamlined and enhanced for accuracy:

Once the patient’s order is received, tests or medications requiring prior authorizations are electronically identified.
Other required details are identified, including provider and facility, patient demographics, test results, and diagnosis.
This data is collected, and an approval request is submitted to the health plan

In this scenario, adding a FHIR-enabled communication channel between the payer and provider, ensures continual access and updates on the PA request and information needed among all involved entities.

FHIR-enabled Prior Authorization Yields Valuable Benefits:

Tapping into FHIR for PA offers quick and flexible utility, enabling clinicians and administrative staff to make instant, informed decisions in real-time when ordering diagnostics and specifying treatments. They can also meet insurance coverage requirements by leveraging Clinical Decision Support (CDS) hooks. The coverage requirements discovery (CRD) component allows payers to share a wide range of information with providers in a context-sensitive manner, including:

Updates to the coverage information
Documentation requirements and rules related to coverage
Forms and templates to complete
Indications of whether prior authorization is required

Real-time Exchange of Supporting Documents using Documentation Templates and Rules

Readily available APIs for Document Requirement Lookup Service (DRLS) can be deployed at the point of care, to enabling providers to secure all needed document templates and requirements to initiate the PA request. The Documentation Templates and Rules (DTRs) component eases the tremendous documentation burden.

DRLS APIs enables a faster and easier way to share the required additional information through the means of questionnaire when submitting the PA request. The questionnaire automatically maps through CQL library files that will help in pre-populating the guiding document, templates, and other pre-population decision criteria.

Robust Medical Necessity Checks

Clinical quality language (CQL) is a FHIR-compliant canonical representation for exchanging clinical knowledge. It helps share information about medical necessity checks and clinical codes when used in real-time to check against Medicare rules. CQL aids in quickly documenting which clinical services or medical devices are covered as part of the patient’s insurance plan. When used together, these FHIR-enabled features execute medical necessity checks automatically with minimal manual verification and validation needed.

One - click Prior Auth Submission with FHIR-enabled Prior Authorization Support (PAS)

For those payers and providers who want accurate, fast, and reliable direct data exchange to reduce manual intervention, FHIR-enabled prior authorization support (PAS) will be a game changer.

CitiusTech’s FHIR-enabled solution offers a FHIR PAS API that enables one-click PA submission capabilities. The PA request can directly be triggered through EHR, sending patient service and care details through FHIR resources to payer applications.

How does CitiusTech’s FHIR PAS solution work?

As shown in Figure 1, the FHIR PAS solution provides a direct data exchange mechanism for PA processing between payer and provider with reduced manual intervention. Using the specific FHIR APIs Providers can trigger the PA request, and get any additional information or dependencies needed for Payer’s review without any delay. Providers receive the updated response from payers through the subscribed mode of updates under the defined SLAs, eliminating complex processes where providers need to keep track of payer-specific rules and coverage plans.

The FHIR-enabled Prior Authorization request will involve FHIR operations which pass in a Bundle of FHIR resources including the authorizing request and any other necessary supporting information. Our prior auth FHIR solution also offers X-12 converter. It translates the triggered FHIR request into corresponding X12 messages and sends them to the health plan, receiving a response, and providing approval or a pending status, due to additional documents required. The response is translated back to FHIR from the delivered X12 messages, and the result is sent to the provider through subscription notification.

Flowchart FHIR..

Fig 1: Architecture for CitiusTech's FHIR-enabled prior authorization support solution.

Choose a FHIR-enabled Prior Authorization Solution that Meets Payer and Provider Priorities

While the CMS rule facilitates FHIR adoption, the key to providers and payers embracing FHIR-enabled prior authorization technologies is a solution that is reliable, easy to use, and fits into the existing technical architecture and operational workflow.

FHIR-enabled prior auth solutions, like CitiusTech’s, can reduce the number of PA transactions requiring human intervention improving PA processing time and real-time decision-making and decreasing unnecessary denials. Most importantly, FHIR-enabled PA processes and technology ensure that appropriate medical care is timely and delivered to patients with the least operational overhead and cost.