Prior Authorization

How docs help develop medical technology that's speeding up electronic prior authorization

| 16 Min Read

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How do you know if something needs prior authorization? Why does prior authorization take so long? What is electronic prior authorization?

Discussing how to speed up prior authorization process using informatics in health care, HL7 and FHIR, computerized physician order entry and more with Viet Nguyen, MD, chief standards implementation officer for HL7 International. AMA Chief Experience Officer Todd Unger hosts.

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Speaker

  • Viet Nguyen, MD, chief standards implementation officer, HL7 International

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Dr. Nguyen: It'll tell you, this requires a prior auth. That's useful information to know, because I know that I can then talk to the patient and let them know that this isn't going to be as quick as we'd like, but we can get this done. 

Unger: Hello and welcome to the AMA Update video and podcast. Last year, CMS released a final rule that made major changes to the prior authorization process. Today, we're talking about one of those changes, electronic prior authorization, and what it'll look like in practice. Our guest today is Dr. Viet Nguyen, chief standards implementation officer for HL7 International in Salt Lake City, Utah. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Nguyen, it is a pleasure to have you with us today. 

Dr. Nguyen: Thank you so much for the invitation to discuss this really important topic. 

Unger: Dr. Nguyen, why don't we just start with a little bit of background for folks out there? You're trained as an internal medicine specialist, I think, also in pediatrics. How did you get to where you are right now in informatics? 

Dr. Nguyen: Many of us have different routes into informatics. Mine started when I was a pediatric chief resident at Cincinnati Children's Hospital. They did a physician order entry implementation. And I felt like it was very interesting work and aligned well with my bioengineering background. 

And so I found out that where I had gone to medical school, here at the University of Utah, we had one of the oldest informatics programs in the country. So when I finished my chief year, I returned to Cincinnati—returned to Salt Lake City to do this informatics fellowship. And I've been doing informatics now for 23 years, along with practicing medicine. 

Unger: I think some things have changed, probably, over those 20 years. It's kind of interesting to think about your career in whole, because you have that unique perspective, having been a practitioner on one side, and now working on the other side of this, on the technical side, to help fix especially this issue around prior authorization. I'm eager to learn more about this very complex topic. How are you approaching it, given your background? 

Dr. Nguyen: I think my clinical training, along with my informatics training and practicing, has been a huge benefit to working on physician-prioritized kind of issues. And we know prior authorization has long been an important topic to clinicians. There have been many reports about how burdensome they are. And so I'm very proud that that background and the work that HL7 and the HL7 Da Vinci Project has done in working on implementation guides. 

When I started in informatics, it was all about just standardizing the data. And we've gone a long way to doing that over the course of the last 20 years. Now what we want to do is start to standardize the workflow so that the data can help the clinician, and in this particular topic, help them be able to reduce the burden of finding out what information they need, whether they need a prior authorization at all, whether or not they have information they have to submit to the payer. Often, they don't know. 

And so bringing that information up forward, then gathering that information using the HL7 standard called Fast Health Interoperability Resources, or FHIR for short, to gather that information and use modern technologies to reduce this burden for them. 

Unger: Well, before we go on, because I want to dig in a little bit more to that response, can you just help the audience out there understand these two terms, HL7 and Fast Health Care Interoperability Resources, a.k.a. FHIR? 

Dr. Nguyen: Sure. So HL7 is Health Level 7. And it is a standards development organization. We are ANSI, or the national standards body, accredited. And what we do is to work with industry, and regulators participate as well, to develop data standards. And one of our three major data standards is the FHIR standard, as I mentioned. But we're also the stewards of the Version 2. So most folks are familiar, if you do technology or implementation, Version 2, which is a lot of the ADT and labs. 

But we're also the stewards of the Version 3 here in the U.S., the clinical document architecture, which many of you, as clinicians, are getting from different EHRs. Or when you're sending information, it may be in the background. So we're the stewards of those three standards. And FHIR is our most recent and most modern standard. It's been around for about 10 years. 

Unger: Now, every physician knows that the prior authorization process is long overdue for an update. Give us a little compare and contrast, old way versus the new way that's supported by FHIR and the other things you're working on. 

Dr. Nguyen: Sure. So as a clinician, I often will order studies, procedures, other things for my patients. And one of the first things I'll ask is, is this service covered under their benefits? Often, I won't know, because I don't know maybe their specific insurance at the time I'm seeing them. My office staff may. And so I would order the service and then hand it off to my back office to do all the data gathering, finding out whether or not it's covered. 

Then, often, they'll say, "Yes, this may be covered and requires a prior auth. Dr. Nguyen, it's 6 o'clock. I know you're working on your charts. But can you fill out this form?" And then I have to fill out this form. And sometimes, information that I should have gathered by a study or something, a prerequisite for a prior auth, is required as part of this prior authorization. So I may have to get the patient back in the office to do this other test or this other study. And so it delays care. 

And then, when I do finish that documentation, and I hand it to my staff, they often have to go to a payer's portal, an online portal, submit this information and then periodically check to see if it's ready. Sometimes they have to make phone calls. And so all those processes are slowed down because they require gathering information or closing an information gap that the clinician has. 

What the FHIR and the Da Vinci implementation guides do is really to address three aspects of the prior authorization. That first step, do I need a prior authorization based on what I'm ordering and the patient's coverage? Our implementation guide can do that in the background. The implementation guide is called Coverage Requirements Discovery. 

Unger: Is that during the procedured during the visit? 

Dr. Nguyen: Yeah, while you're in the room, while you're ordering. And it'll tell you, this requires a prior auth. That's useful information to know, because I know that I can then talk to the patient and let them know that this isn't going to be as quick as we'd like, but we can get this done. So once I know there's a prior auth, the second gap is, well, what information do I have to submit? 

Our document templates requirements implementation guide has the ability to embed within the patient workflow, inside the EHR, so not the portals, the set of questions that a payer may ask. You can think about it as kind of an electronic form. But in the background, using standardized data, we can gather that information, present it to the clinician, and say, here's what we're going to submit to the payer. Is it correct? Do you want to add any narrative? Sometimes we don't have standard data. So we have to do a little narrative. 

But by knowing what I have to submit as information, I'm closing a gap. I'm reducing that burden, because otherwise, I'd have to go to a portal to get that form. And then, using the FHIR technologies to gather that standard information, that's in the EHR as part of the certified EHR technologies that hopefully, everyone is using in the audience. 

We can gather that information. So blood pressures, lab tests, vital signs, past medical history, things like that are now standardized and can be gathered electronically by the FHIR technologies. And then we can submit them to the payer. Now the payer has structured data that they can use to evaluate the prior authorization, maybe ask for additional information. We want to try to minimize that. 

But then you can submit that prior auth electronically using FHIR and then get the status using FHIR. So you don't have to go to a bunch of different portals, checking for the status of prior auths, which can slow down the day, causes burden for the back office staff. And we want to reduce the burden for the clinicians. We know that their time in front of their patients is very important and vital. But that time, what we used to call the pajama time, is also important time. And by not being interrupted by the follow-up things during that pajama time, we're reducing burden in a different way. 

Unger: I mean, it really sounds miraculous. When you were going through the list of things that you typically confront, I think my head was hurting. And I'm not even the one dealing with that kind of burden. So in the course of your normal workflow, number one, you're identifying whether there's coverage for something like this. Number two, is there a prior authorization? Three, what are all the kind of data points I need to collect along the way so I'm not having to repeat the visit or spend my pajama time, as you point out, doing that same thing? 

Then I can submit it. And then, instead of having to check over and over and over again for progress, you're able to let that happen automatically. And you can tell when there's an approval. Do I have the process right? 

Dr. Nguyen: You summarized it perfectly. And so that helps me know that I've tried to explain it well. 

Unger: I am listening. But it makes sense to me. So that's just truly amazing. Have you started to see this process roll out? Or what can we expect in terms of timing? 

Dr. Nguyen: Yes. So it's important to note that this FHIR technology is not new. We're using modern, what we call application programming interfaces, technology that your audience has probably used a dozen times over the course of the day, whether they're getting directions from Google or looking up things in Facebook, so modern technologies. That's really important. 

But also, the ability to bring this information up to the clinicians is really vital. And this is only one aspect of a myriad of areas that the Da Vinci Project is working on, along with HL7, to improve the delivery of care and reduce other kinds of burdens for the clinicians, like exchanging clinical data, getting clinical data from payers. 

And a strong driver for this entire approach has been some regulatory activity from CMS. So this prior authorization, this set of guides that are strongly recommended as part of the CMS 0057 rule, also known as the burden reduction rule—it has a much longer name. But these technologies build upon the last 10 years of growing FHIR and standardizing data to the point where we can start to really get a lot of value from the standard data in standardizing workflows. 

Unger: Now, one of the themes that I am sensing when I talk to different physicians who are working on the technology side is that unlike maybe the initial rollout around EHRs, a lot of these advancements are reducing burden for the physician. And they are also probably making the patient experience a lot better. Are you hearing from the patient's angle that this creates an improved process? 

Dr. Nguyen: I think, in time, more and more patients, because we have these patient access API rules back from 2020, have their data available. So if you think, in a parallel patient, individuals who are really engaged in their finances can use technologies that can gather their financial information and help them be able to address them more actively. 

My hope is that these technologies will allow patients to see their clinical data and be more engaged in the shared clinical decision making that they have with their clinicians, not to—to be a partner, I should say, with their physicians in their care. 

Unger: It's no fun either, on the patient side, waiting for that prior authorization to come through, and I'm sure, having to backtrack and get additional information, so really reducing the burden for everyone involved here. So that is a real win-win. And thanks to this CMS final rule, there is a lot of work, as you point out, already in progress to make it a reality. Obviously, that's going to take a lot of coordination from a lot of different people. What do physicians out there need to know about their role in all of this? 

Dr. Nguyen: So one important aspect is, first, this particular CMS rule that we're referencing, this burden reduction rule, it applies to federally funded health care, so Medicare Advantage, CHIP, and those. So it doesn't necessarily cover all commercial plans. But we hope that through this experience that we've had, that commercial payers will see the value of this and make it available for their commercial patients as well. 

We had some very positive response from the clinicians as part of a pilot study in the Pacific Northwest, with MultiCare and Cambia as the primary pilot group. And once they—they started rolling out just a handful of procedures that would use this FHIR technology. And it turned out, the clinicians wanted more. They wanted to be able to do this process with other procedures. 

And so, as we start to grow the number of procedures, and clinicians can start to see the value of this, I firmly believe they'll see that it is a burden-reducing approach. Even if it takes just a minute or so longer while the patient is in the room, we're saving time on the back end. 

Unger: Absolutely. Now, you talked about, earlier, the role that HL7 plays in making this work. And physicians can get involved there as well. Tell us more about that. 

Dr. Nguyen: Yes. We love to have clinicians involved in the work we do, because most of us are technologists and standards developers. I'm fortunate to be a clinician. And that perspective of the clinician is very important, because the information that they need during a particular workflow, they can share with these standards developers. 

So as we develop standards, understanding workflow and the data requirements is an essential part of the process we have. And then, once we understand that workflow and the data, we start to develop these standards. We test them. We iterate over the specifications and make sure that they're fit for purpose. And then we ballot them and publish them. 

And the role of the clinician along the way is really to help make the standard better. So we have opportunities. We have different work groups. We have a lot of clinicians in our EHR workgroup, and talk about things like burden reduction and AI, and other aspects of clinical care to try to help improve our standards. And then we like to engage them in our clinical work groups. So there are lots of opportunities for clinicians, especially those who are a little more techy, like I am, to get engaged. It's a lot of fun to start to learn applied informatics. So we encourage clinicians especially who have that background to get engaged as well. 

So we are a big tent kind of organization. We'd like to have more and more clinicians and other health care professionals who understand the workflow, because again, we're physicians. We deliver care. But we also have our folks who do utilization management, who work with the insurance companies. And their understanding of the current workflow is very important to us as we develop new workflows and new standards.

Unger: Wow. Having physicians at the table for technology innovation, focusing on reducing administrative burdens and enabling physicians to spend more time with their patients. This sounds like a great development. Thank you so much for joining us today. And that was just a really great overview of the work that's going on and a glimpse of the future of prior authorization. 

As part of our efforts to make technology work for physicians and removing the burden of prior authorizations, the AMA is also a member of HL7. So if you have any questions about electronic prior authorization or insights to share, please reach out to us so we can pass our comments on. That wraps up today's episode. 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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