The vast majority of practicing physicians surveyed (PDF) by the AMA say prior authorization has a negative clinical impact for their patients. The payer cost-control practice wastes physicians’ time and delays patient care.
That is why Ochsner Health is finding a way to mitigate prior authorization, and it's relying on an unlikely resource to make the change: the EHR.
Ochsner Health is using the EHR to increase instantaneous prior authorization approvals and lower the number of denials.
"The whole process has really decreased authorization time and improved authorization efficiency. When you talk to the staff that do this every day, they are finding this incredibly transformative to the work that they do," said Philip Oravetz, MD, a family physician and chief population health officer at Ochsner Health, which is a member of the AMA Health System Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Dr. Oravetz talked about how Ochsner Health is using the EHR to speed up prior authorization approvals during a recent episode of “AMA Update.”
Instant approval for prior authorization
At Ochsner Health, physicians and other health professionals no longer need to log onto a payer website. Instead, they can manage all payer communications through the EHR.
Since making this change, Ochsner receives automatic approvals about half the time for a select list of procedures. This will expand over time as they get more experience.
Even when they don't get immediate approval, the requests that took days or weeks to answer are now being evaluated in hours.
"It's speeding up the process," Dr. Oravetz said. "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."
Fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians.
Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Find out how the AMA is tackling prior authorization with research, practice resources and reform resources.
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Institutions in this article have been honored by the Joy in Medicine™ Health System Recognition Program.
Fewer prior authorization denials
Ochsner Health is working towards fewer prior authorization denials by using the EHR to communicate directly with payers.
Dr. Oravetz said prior authorization denials often result from a lack of clinical documentation. With communication routed through the EHR, that documentation becomes far easier to share, either initially or as soon as the health system realizes what additional information the payer requires.
"It's really a win-win for everybody,” he said. For physicians, it’s a win because they “get faster answers and understand what documentation they need,” while payers appreciate the efficiency of receiving EHR documentation.
“Most importantly, it's a win for our patients,” Dr. Oravetz said. “Patients are able to get their care faster, more efficiently and more appropriately in an evidence-based way."
Other prior authorization improvements
The Centers for Medicare & Medicaid Services’ rule finalized earlier this year aims to help improve how health information is exchanged between health systems and government-regulated payers, including Medicare Advantage Plans. These payers have until 2027 to implement certain changes.
Because of that rule, Dr. Oravetz said more health systems will begin looking to their EHR to speed up the prior authorization process. New technologies, including augmented intelligence (AI), will also be key to achieving improvements. By this time in 2025, Dr. Oravetz would not be surprised if Ochsner Health's process was standard practice across the country.
"Hundreds of hours of staff time has been saved so far," he said. "That's going to turn into thousands. …This really is a very material improvement in the current process."
Patients, physicians and employers can learn more about reform efforts and share personal experiences with prior authorization at FixPriorAuth.org.
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