IDC Perspective: Prior Authorizations Deep Dive — Feasibility Now Foreseen to Solve This Health Ecosystem Menace

IDC Perspective: Prior Authorizations Deep Dive — Feasibility Now Foreseen to Solve This Health Ecosystem Menace

This IDC Perspective outlines the context, pain, and initiatives undertaken by payers, governments, organizations, providers, and vendors to address the prior authorization annoyance in the health ecosystem."Although prior authorization has been historically troublesome for healthcare stakeholders across the board, there is a light at the end of the tunnel," says Jeff Rivkin, research director, Payer IT Strategies at IDC Health Insights. "Data-driven collective decision making is key to solving prior authorization. All major players in the health ecosystem have issued a 'Consensus Statement on improving the Prior Authorization Process,' value-based contracts are driving collaboration, dozens of vendors are attacking the problem, and technological solutions such as FHIR, RPA, AI, ML, and CDS are at the forefront of healthcare IT's contribution to fixing prior authorization. A collaborative approach is the only way to tackle the issue. We now have the means and motivations to address this controlling transaction that exemplifies the pain caused in the fragmented healthcare/payer environment."

Please Note: Extended description available upon request.

Executive Snapshot
Situation Overview
What Is (Advanced) Prior Authorization?
Pain Points
Payers' Pain Points
Employer Pain Points
Providers' Pain Points
Members/Patients' Pain Points
What Are Payers Doing to Address These Pain Points?
Staffing Up
Health Information Exchanges
Electronic Submission
Operating with Transparency
Not Treating PAs Only as a Back-Office Problem
Unfortunately, Only Solving for the "Happy" Path
Investing in Solutions That Work for a Certain Payer or Certain Specialty
Audit-Based Systems: Gold Carding Physicians
Sunset Programs
Increased Information at the Point of Care
What Should Payers Pay Attention to Now?
Prior Authorization Under Value-Based Payment Contracts
Government and Organizational Initiatives
American Medical Association Prior Authorization Initiatives and Collaborations
CMS Interoperability and Patient Access Final Rule (CMS-9115-F)
CMS Documentation Requirement Lookup Service
HL7 Da Vinci Project
ONC P2 FHIR Task Force
Federal Legislation
State Legislation and Initiatives
CAQH CORE's Operating Rules for Prior Authorization
American College of Radiology's Appropriateness Criteria
Advice for the Technology Buyer
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