Clinical prior authorization often requires health care providers and their staff to provide clinical and administrative information to utilization management personnel by phone, fax, or through a standalone portal. This information is evaluated against medical necessity criteria to determine whether a patient’s test or treatment will be approved. This process can add costs to the healthcare system – it can be labor-intensive, costly, and can occasionally delay patient care. Moreover, most of the clinical information required for an authorization determination has already been documented by providers in the EHR, yet providers and their staff often need to repeat the information because the information in the EHR is not integrated with the prior authorization process.
This redundancy is occurring at a time of increasing health care costs and physician burnout. A study published in Health Affairs showed that provider interactions with health plans, including prior authorization, can result in approximately $83,000 per physician per year in additional costs. Another study published in Health Affairs showed that $23 to $31 billion is spent annually on administrative functions annually, including prior authorization, in the United States. Integrating and automating clinical prior authorization can potentially reduce administrative costs and improve the patient and provider experience.
Aetna has selected Stanson Health, a leading clinical decision support and analytics company, to help automate clinical prior authorization using information readily available in EHRs. This will involve integrating information in the EHR with the clinical prior authorization process, including an evaluation of discrete data elements and some free text information, for automated evaluation of medical necessity criteria. Stanson has developed a platform to perform this work during the past 4 years, including a content management system, a cloud-based rules engine, analytics product, and natural language processing capabilities. This platform is being used by more than 300 hospitals and the health care providers affiliated with their organizations.
Scott Weingarten, MD, Chairman of the Board of Stanson, said “Virtually all health care providers dislike the inefficiencies that accompany prior authorization today. One day people will look back at 2017 and wonder why clinical prior authorization required a labor-intensive process outside of the provider workflow during the digital health era. Aetna has been forward thinking and is committed to improving the member and provider experience, and to reducing administrative costs, as they work with Stanson to transform clinical prior authorization.”