Employers have been asking health insurers for years to speed up and simplify efforts to screen workers’ requests for coverage for CAT scans, specialty drugs and stomach operations.
Insurers told state insurance regulators Tuesday that, this time around, they think they really can make prior authorization processes work better.
New data standards and new artificial intelligence tools should help insurers increase the percentage of approvals provided for complete files “in real-time,” or within a few minutes, to 80% in 2027, from about 20% today, insurers said in Minneapolis, at a meeting of the National Association of Insurance Commissioners’ Regulatory Framework Task Force.
Insurers can improve approval processes by using the Fast Healthcare Interoperability Resources data-sharing format, or FHIR standard, for all plans, not just Medicare and Medicaid plans, according to Jeannette Thornton of America’s Health Insurance Plans and Monica Auciello of the BlueCross and BlueShield Association.
The Regulatory Framework Task Force included a comment letter from AHIP and the Blues and an AHIP prior authorization slidedeck in a meeting packet posted on its section of the NAIC’s website.
AI: AHIP members and the Blues can also improve prior authorization processes by further reducing the number of procedures subject to approvals and by continuing to ensure that live-human medical professionals will review any denials recommended by automated systems, AHIP and the Blues said in their comment letter.
“AI will only be used to facilitate quicker approvals, not for denials based on medical necessity without a clinician review,” according to the AHIP slidedeck.
A patient advocacy group’s view: Representatives from the National Health Law Program, a patient rights group, questioned how realistic the insurers’ promises are.
The commitments “largely repeat existing obligations,” NHELP said in a comment letter included in the meeting packet. “Notably, it’s unclear whether any consumers, consumer groups or provider associations participated in shaping them.”
The prior authorization backdrop: The insurers contend that the critics underestimate the amount of work insurers have already done to streamline prior authorization processes.
The processes now apply to fewer than 4% of commercial prescription drug claims and fewer than 7% of commercial medical claims, according to AHIP data.
One of the obstacles to quicker processing is that providers still submit 47% of the prescription prior authorization requests and 45% of the medical services prior authorization requests through the phone, postal mail or facsimile machine transmissions rather than through standard electronic systems, AHIP said.
Many requests for prior authorization are incomplete, and insurers or plan administrators end up approving about 10% of the prescription drug authorization requests and 97% of the medical services authorization requests, AHIP said.