Dive Brief:
- Epic has launched a tool that enables clinicians to instantaneously check whether an insurer requires prior authorization for medical treatments, the electronic health record vendor announced Monday.
- Four health systems — Ochsner Health, Froedtert ThedaCare Health, Denver Health and Summit Health — are the first to adopt the tech, which lives inside Epic’s electronic health record.
- The health systems will be able to see whether a prior authorization is required with insurers UnitedHealthcare, CVS’ Aetna and Network Health. Sixteen additional payers are currently testing the interface, Epic said.
Dive Insight:
Prior authorization, which requires patients and their doctors to request coverage for a medical item or service before it’s provided, has long been a pain point for clinicians, who argue it blocks timely care and drowns them in needless paperwork.
Despite efforts to digitize prior authorizations, the process remains largely manual — forcing clinicians to chase down insurers by phone or fax, juggle multiple insurance portals and stay up to date with shifting requirements.
Epic is aiming to alleviate these issues with the new application programming interface, or API, called Coverage Requirements Discovery.
APIs are sets of rules that enable computer programs to communicate directly with one another. This one, built by international data standards organization Health Level Seven International using the Fast Healthcare Interoperability Resources standard — a widely recognized framework for health data exchange — lets providers check whether a medical service requires prior authorization immediately. It eliminates the need for clinicians to track down specific insurer requirements, according to Epic and participating systems.
“This will reduce administrative burden, improve efficiency, and minimize delays in patient care,” Melissa Woods, Ochsner Health’s assistant vice president of revenue cycle and financial clearance, said in a statement.
The launch will also help providers meet the requirement of a federal interoperability rule that requires most Medicaid, Medicare Advantage and Affordable Care Act marketplace insurers to implement prior authorization APIs by Jan. 1, Epic said. The APIs must include a list of covered items and services, guidance for documentation requirements and support for completing requests and responses.
The sweeping final rule also requires insurers to turn around prior authorization decisions faster, provide a specific reason for denying a request, and publicly report certain prior authorization metrics. Those provisions went into effect at the start of this year.
The rule is one of several efforts from regulators to improve the much-maligned prior authorization process. In May, the agency secured a pledge from companies participating in the Health Tech Ecosystem, an initiative to increase access to digital health tools and improve health data sharing, to address challenges in prior authorization.
Insurers also say they’ve taken steps to streamline their preapproval requirements. Last summer, the Trump administration secured voluntary pledges from insurers to reform prior authorizations, and as of this spring, the companies say they’ve cut 11% of the policies.
