Prior Authorization expansion on the move

Prior Authorization continues to be a significant barrier for patients and providers. It has caused greater financial waste for providers and increased delays for patients.  

According to the AHA survey, one 17-hospital system reported spending $11 million annually just to comply with health plan prior authorization requirements. 

Efforts to streamline and standardize have failed since May 1, 2020, when the Final Rule implemented the first phase of CMS Interoperability. This lack of standardization and adoption continues to create chaos and duplicative work. Phone, fax, paper forms, and inconsistent portals contribute to this ongoing headache. While there is a standard available for electronic prior authorization transactions, adopted by HHS under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), many payers and providers do not use this adopted standard (the X12 278 Version 5010). Instead, payers build proprietary interfaces and web portals through which providers submit their requests, and both still frequently resort to phone calls or faxes to complete the process for a response. 

The 2021 report showed an incremental increase in using the X12 278 prior authorization standard of 26 percent. 

2023 will hopefully be different with the December 6, 2022, CMS filing of the Proposed Rule to expand access to health information and improve the Prior Auth process. This combined with the data from workflow systems, PMs, and platforms like AuthParency, leads to improved efficiencies and data tracking.  

Continue to follow Spark Advisory Network for developments, updates, and innovative technologies for prior authorization. 

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