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AMA Update
How to speed up your prior auth process using EHR data exchange
May 3, 2024
What is the new CMS rule for prior authorization? Why do prior authorizations get denied? What are the benefits of electronic health information exchange? Our guest is Philip Oravetz, MD, chief population health officer at Ochsner Health. AMA Chief Experience Officer Todd Unger hosts.
- Check out prior authorization cheat sheet resources.
- AMA President Dr. Ehrenfeld explains CMS prior authorization final rule.
- Read about the changes coming in CMS Interoperability Rule 2026.
- Get involved! Patients and physicians can share prior authorization stories.
- Access AMA prior authorization resources and research.
- Free prior authorization templates and model legislation.
- Stay up to date on the AMA's advocacy efforts to fix prior authorization.
- The AMA is your powerful ally in patient care. Join now.
Speaker
- Philip Oravetz, MD, chief population health officer, Ochsner Health
Transcript
Unger: Hello, and welcome to the AMA Update video and podcast. Today we're talking about the innovative way in which one health system is using its EHR to save time on prior authorization. Here to tell us all about it is Dr. Philip Oravetz, the chief population health officer at Ochsner Health in New Orleans. I'm Todd Unger, AMA'S chief experience officer in Chicago. Dr. Oravetz, welcome.
Dr. Oravetz: Thanks, Todd. It's a pleasure to be here this afternoon, and talk about some really innovative work that we're up to here at Ochsner.
Unger: Absolutely. Well, we'll start with a little bit of background. Over the last few years, advocacy at the state and federal level has helped to reduce the burden of prior authorization. We've heard a lot about that at Ochsner. You're leveraging technology to reduce this burden even more. Really excited to hear about how. Tell us.
Dr. Oravetz: So before we jump into the details of prior authorization, really want to level set a little bit about the platform we're using with our EHR. We started exchanging data with our major payers about three to four years ago, and that has seen explosive growth throughout the country.
Today, over 200 organizations are exchanging data with 16 major payers and covering over 100 million lives. So what we've seen is really explosive growth of data exchange between providers and payers. It started out, really, in the area of quality improvement and documentation excellence. But now we've moved forward with prior authorization, and that activity is going very fast. And we're seeing very good results that we can talk about further.
Unger: So, how does that then tie-in to the prior authorization workload?
Dr. Oravetz: So the first thing is, when you're exchanging data that is now incorporated into the prior authorization process. The first thing I can say is our preservice teams and prior authorization teams only log into Epic. They don't go to any payer websites. They don't have additional logins. They use our EHR to communicate with the payers.
So all requests now are put through, or the request that we've agreed early on, are put through our EHR platform, go directly to the payer. And for the subset that we have defined in our early on pilots, we're getting—about half of the time we're getting instantaneous approval. So it's speeding up the process. If there are issues, we can then exchange data back and forth between us and the payer.
The whole process has really decreased authorization time, improved authorization efficiency. And I will tell you, when you talk to the staff that do this every day, they are finding this incredibly transformative to the work that they do.
Unger: I'm curious if you have a story for us, or a kind of a case study or example that would illustrate how the experience is different?
Dr. Oravetz: Yes. As I say, you know, the staff never leaves our EHR. So that, in and of itself, is a major plus. As I described, we as clinicians and the rest of our staff do one thing routinely every day. They log into our EHR. And so what we're finding is, you know, when that data gets exchanged in real time, we're getting answers faster. If there are issues identified, we're able to then communicate. We're able to send clinical data right through the EHR to the payer. And what we're finding is that our case studies are showing lots of auto approvals.
The other thing that other organizations are demonstrating as well is the amount of denials are decreased rapidly. The number one reason we're finding for denial is lack of clinical documentation. And we now have a way to provide that either right on the front end, or once we know we need it, we can send it immediately. So I know I get asked questions a lot. When you share data, doesn't that increase denial rates? In point of fact, it's having the opposite effect. Denials go down when we share documentation from the health record.
Unger: That's really amazing. I'm curious, was this a hard thing to negotiate with the payers to change the system?
Dr. Oravetz: So I get to sit at the table with the payers. You know, they are driving for efficiency administratively as well. So I think it's really a win-win for everybody. It's a win for the providers, who get faster answers and understand what documentation they need to demonstrate. It's a win for the payers because they're getting more efficient.
But most importantly, it's a win for our patients, right? Care isn't getting delayed. Patients are able to get their care faster, more efficiently, and more appropriately in an evidence-based way. So it's really a win all around. So everybody's really on board because they see the benefits, particularly to the patients.
Unger: And speaking of win-win, this has to have a dramatically positive effect on your physicians and the rest of the team. I know our research core shows that prior authorization has a huge impact on physician burnout. Tell us a little bit more about the impact of the change that you're seeing on your own staff.
Dr. Oravetz: I think, when we talk to our preservice department, they are very pleased with where we are in the process. And we know, as this functionality develops in the platform, it's just going to bring more and more efficiencies. In point of fact, I think as we look forward two or three years, a lot of this is going to be automated.
And we're very much in line with the new regulations that have come out, right? We know that by 2027 a lot of prior authorization activities need to be automated in an electronic format. We're really well on the way to meeting that requirement already in 2024.
Unger: That's amazing. Any kind of round numbers or ballpark you can show the impact of this time wise?
Dr. Oravetz: We are showing that there's, really, there's a decrease in the time to get an answer on our prior authorization requests. Before it could take days to weeks. Now it's taking hours to days.
Unger: That's amazing. And we all know how important those hours are. What did it take to get the process set up in your own EHR?
Dr. Oravetz: So we're working with our EHR vendor. And we've been through this. You know, as I described early on, there are over 500 data connections now live between payer groups all over the country and provider groups. And so there's a pretty robust history right now as to how you set this up, and how you follow the rules of the road and how you exchange data. We have control over what we share and the payers do as well. And so we've come to a real understanding that, you know, we're sharing what is HIPAA compliant really for treatment and authorization. So, it's gone swimmingly well so far. And as the platform evolves, we'll continue to bring, I think, even more benefit.
Unger: You know, I don't think there's a practice out there that doesn't want to reduce the burden of prior authorization in some way. Is this kind of change that you made exportable to other practices, or is something unique about your own system?
Dr. Oravetz: No, this is—we're on a standard platform. So this will continue to grow. As I say, you know, over 200 organizations are now exchanging data with their payers. This is going to be standard of care probably within the next 6 to 12 months. Everyone's going to be using this. And we're adding more and more functionality. So the efficiencies are only going to increase.
And you asked me earlier about what practically have we seen? Literally, just hundreds of hours of staff time that has been saved so far. That's going to turn into thousands. And when you multiply it across 100 million lives on the platform, this really is a very material improvement in the current process.
Unger: Wow. I don't know any physician out there who wouldn't rather spend their time in patient care than on prior auth. So that is really impressive. I'm curious now that you've got this on its way, are there other ways that you're looking to use the technology to reduce the burden of prior auth?
Dr. Oravetz: Yes, I think it's going—I think you're going to see more and more automation in the coming years. And again, this is leading up to, I say, the new CMS requirements for data exchange that are coming for 2027. So I think there's going to be more and more automation. We're doing that within our EHR already in terms of—you know, I think AI is going to hit this area in a very big way in the next two to three years as well. As I say, we're pretty early on in AI and really understanding what it's going to, how it's going to improve our practice of medicine. It's going to be big in this area as well.
Unger: Well, Dr. Oravetz, thank you so much for joining us. What a great example of how technology can be an asset, not a burden to physicians. Fixing prior authorization is one of the AMA'S top priorities. To support this work, become an AMA member at ama/assn.org/join.
That wraps up today's episode, and we'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama/assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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