Imagine if the aviation industry was run like healthcare. For both industries, health and safety is critical.
There are strong parallels between aviation and healthcare. The safety of the passengers is critical to aviation, the health and safety of patients is critical in healthcare. Let’s imagine for a moment if the aviation industry was run like healthcare.
Think of airports as health plans. Pilots are the providers. The airlines are health systems. We are the passengers/consumers.
Now imagine if each airport had its own unique traffic control system and they managed their own TSA and baggage allowance rules.
Imagine taking a trip, not knowing your baggage allowance. Not knowing the process for getting to your flight. Not knowing if you should be at the airport one hour, or four hours before your flight? This equates to the business problem we have in healthcare today with Prior Authorization.
Providers don’t know what rules apply for which health plan. Patients are confused because they don’t know what rules apply in their particular situation. This is why we desperately need regulation to standardize how Prior Authorization works. It is the biggest pain point and it harms patients.
Yes, there have been moves to automate and digitize the process, but individual Payers have acted alone. Piecemeal automation has turned paper into PDFs. Faxes replaced with web portals, all with limited success. Providers still copy and paste from their EMR. They print. They fax. The health plan then has to convert these requests into something that they can process. This is a heavily manual, human-powered process.
This is a crazy situation! We desperately need regulation! Those regulations must address how providers can discover whether a prior authorization is required and, if required, what information needs to be sent with the request. The required information should be extractable from the EMR automatically.
Today each health plan may be efficient in their handling their Prior Authorizations. They may be member friendly, but the situation from the Providers perspective is a complex landscape when they deal with multiple health plans, each with their own rules.
The situation today is confusing, inefficient and time-consuming. Regulation can help resolve this. The standards are ready to address the Prior Authorization enquiry and submission process. Health Plans must apply these standards consistently. Implementation still lets Health Plans choose what requires Prior Authorization, which Providers need to submit Prior Authorizations, and the data to be collected.
Answering the question of whether a Prior Authorization is required and the communication of which data needs to be supplied to support a Prior Authorization submission MUST be standardized. If we fail we will persist the current inefficiencies. Inefficiencies that cost $24 Billion each year to perform Prior Authorization.
This is a transformative moment for healthcare. It is an unprecedented opportunity to implement a process that is both appropriate and can be determined in real time. To achieve this we need standardization. To achieve standardization we need regulation to force industry adoption. At Onyx are building the infrastructure to support standards-based Prior Authorization. If you want to know more, please contact us.