A new Council for Affordable Quality Healthcare (CAQH CORE) report said that Medicaid could save more than $4.8 billion annually if it moved to fully electronic transactions.
CORE said more than half of Medicaid enrollees are in plans without electronic prior authorization. Only 44% of Medicaid recipients are in currently in plans with the automated claims processes.
In comparison, 78% of commercial plans and 75% of Medicare Advantage plans have electronic transactions, according to the report. Efficient operational systems such as electronic transactions can reduce administrative costs and improve patient care by providing quicker approvals.
CAQH CORE is a group of more than 130 public and private healthcare companies that created operating rules for electronic sharing of administrative data almost a decade ago. CORE Certification includes four phases of operating rules that deal with a different set of administrative transactions.
George Conklin, CAQH CORE board member and CIO of CHRISTUS Health in Irving, TX, said in a statement that CHRISTUS has found working with CORE-certified Medicaid plans to be “more efficient and predictable.”
The report, published Monday, said Medicaid payers can reduce overhead by adopting all four phases of operating rules for electronic transactions. At the state level, Florida payers could save $177 million annually, Illinois could save $294 million and California $655 million if their Medicaid claims processes were to go fully electronic.
Payers are increasingly turning to electronic transactions such as prior authorizations. Manual prior authorizations can create administrative issues, lost productivity and result in delayed or avoided care. CAQH estimates that electronic transactions can save $6.84 per transaction alone.
Doctors have also spoken out about the hassle of prior authorizations. The American Academy of Family Physicians called the practice family physicians' "number one administrative burden."
An American Medical Association survey earlier this year found that 92% of physicians said prior authorizations hurt patient clinical outcomes. Also, at the time of the survey, one-third of reporting doctors noted they had waited at least three business days in the last week for the payer to give the OK, delaying necessary patient care.
Multiple efforts involving both payers and providers are looking at ways to improve prior authorization processes. One notable coalition involves stakeholders like the AMA, American Hospital Association and America's Health Insurance Plans, and recently wrote a consensus statement highlighting their shared commitment to industry-wide improvements to prior authorization and patient-centered care.
Proponents of the automation argue that helps patients along with healthcare companies. A recent case study of Milwaukee area nonprofit Aurora Health Care's electronic prior authorization system from Surescripts found that patients were able to receive their drugs more quickly with less administrative work for providers.
Plus, Luke Forster-Broten, manager of product innovation at Surescripts, recently told Healthcare Dive that Surescripts has seen a 1% increase in first-fill adherence for patients where electronic prior authorization is available. In Milwaukee, Aurora enjoyed an 8% first-fill adherence after a few months.