There is one thing more frustrating than a delayed flight: an on-time flight, with a delay mid-air. The pilot announces some airline jargon about a gate change and holding pattern, and next thing you know you’re circling.

Your estimated arrival time is now going up, and you’re going nowhere! An element of this frustration is because you see no end in sight, and it’s just wasted time (and fuel) as you wait. Not to mention that relative who is also now circling the airport arrivals section, and promising to themselves never do this pickup favor for you again.

Well, this is the core of many healthcare providers’ frustration with the prior authorization system. It seems as if we are just circling and circling to accommodate insurer requests, but getting nowhere by doing so. Let’s back up a bit and give you the 30,000-foot view for a general big picture of the prior authorization process.

Prior authorizations were introduced in the 1960s. Originally, they were designed as a measure to ensure appropriate utilization of healthcare services, specifically to avoid unnecessary hospitalizations. However, with time these requirements have evolved into a complex process with far-reaching implications. While insurers maintain the primary purpose of PA is to safeguard patients from unnecessary and costly interventions, concerns have arisen regarding the potential misuse of PA as a cost containment tool. 

Quite often, providers see authorization issues leading to delays in patient care and unjust denial of medically necessary treatments.

Cue the appearance of third-party solutions: to address the challenges posed by PA requirements, various third-party solutions have emerged. One of them involves the implementation of software that enables insurers to create prediction models based on historical data and member acuities. 

These predictive models aim to identify cases where PA may be warranted, thereby streamlining the process for legitimate cases while reducing administrative burden by weeding out those deemed unwarranted.

Conversely, some provider-focused software has been developed to counteract this insurer pushback. Utilizing automation and, yes, even artificial intelligence. With this, providers can identify and address common reasons for PA denials, push for consideration when appropriate, bolstering the basis for appeals, and ultimately ensuring a more transparent and efficient PA process.

This is where the circling and dizziness feelings ensue. As each side continues to create solutions to counteract the other’s last attempt to circumvent it, we are just whirring in a circle of reactive solutions instead of really thinking of answers that will be amicable for both parties. A solution is needed that fosters collaboration between healthcare providers AND payers. After all, both parties share the common goal of delivering quality healthcare, but the misalignment in their objectives at this point is hindering the process.

Let’s be clear. Healthcare providers understand the necessity of PA screening, acknowledging its role in promoting evidence-based care and cost-effectiveness. On the flip side, insurers are also aware of the growing concern that some patients are being denied essential treatments recommended by reputable providers, due to rigid PA criteria.

So back to our airport analogy. I’d like to propose a “TSA PreCheck” style solution to this conflict. As we all know, TSA has extensive security measures in place. Line up, IDs out, shoes off and then pat downs if you look like you’re smuggling more than 3.4 ounces of liquid (gasp!). 

But then there are those who qualify as trusted travelers with TSA PreCheck.

Less scrutiny, shoes stay on, even laptops can stay put. The concept is that once they have been vetted and proven to be trusted, they are given more leeway. Of course, at any time they can be pulled over for a spot check; even lose this privilege if there is any reason for concern.

Imagine we introduced a similar collaborative technique for prior authorizations. Here is how it would fly:

Insurers introduce a tiered methodology to provider credentialing based on providers’ historical adherence to evidence-based practices, patient outcomes, and avoiding rehospitalizations. Providers with a proven track record of delivering high-quality care could be granted Tier 2 status. This allows for expedited PA approvals, and recognized standard procedures that do not require PA, thereby reducing administrative burdens.

By establishing this, a provider is motivated to maintain this status and, therefore, ensures their adherence to insurer rules and directives. Insurer relaxes the heavy scrutiny, but reserves the right to periodically check on provider observance of obligations and red flag or demote to Tier 1 as necessary. 

This can really be a win-win situation that can lead to more collaboration with the insurer, and the provider finally being on the same page once and for all.

Now nobody said this will be easy to implement. It will likely need to begin with conversation between leadership on both ends of what the criteria would be, and what effect this tier-based approach will have on the current PA process. So, at this point, please look at this as an idea. 

An idea with only the best interests of everyone in mind, to solve an industry problem that has been going on for too long. After all that’s how all good ideas “takeoff” — it all starts with an idea. Let’s just hope this one lands!

Steve Shain is Partner, EVP of Contracting at LTC Ally. His team negotiates managed care contracts and authorizations on behalf of healthcare providers. Contact him directly at [email protected].

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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