1 prior authorization challenges & best practices · 2019-10-30 · 1 t his is. caham annual...

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T H I S I S

CAHAM Annual Conference October 29, 2019

Steve Kim, MD, MBA, MSCECo-Founder | Voluware, Inc

&Vivian Perez

Clinical Authorization SupervisorPatient Access Services, USC Norris Cancer Hospital

Prior Authorization Challenges & Best Practices

(A Systems Thinking & First Principles Approach)

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Steve Kim,M D , M B A , M S C E

• Attending Surgeon, Pediatric Urology• CHLA Physician Champion – EHR• CHLAMG Steering Committee IT/Rev Cycle• Assistant Clinical Professor, USC Keck SOM• Value-Based Delivery Researcher• Director, Clinical Research Informatics

• Co-Founder, Chief Strategy Officer• Voice of the Customer

Our Backgrounds

Vivian Perez

Clinical Authorizations Supervisor Patient Access ServicesKeck Hospital of USCAuthorization SME

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My Prior Authorization Journey

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Not for distribution, reproduction without consent

Systems thinking is a method to analyze relationships between a system’s parts to understand the potential for better decision-making. A systems approach consists of elements, interconnections,and an overarching purpose.

Systems Thinking First PrinciplesFirst principles thinking requires you to dig deeper and deeper until you are left with only the foundational truths of a situation.

https://jamesclear.com/first-principleshttps://gofore.com/en/what-is-systems-thinking-and-how-should-i-use-it/

Frameworks for Problem Solving

Listen to People

https://jamesclear.com/first-principles

https://gofore.com/en/what-is-systems-thinking-and-how-should-i-use-it/

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1. Manual authorization submission process

2. Informational complexity – what needs auth?

3. Communication between teams

4. Denials management – front-end feedback

Key Prior Authorization Challenges

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Ambulatory Clinics

Centralized Patient Access

Professional Authorizations

Facility, technical/ancillaryNotice of AdmissionsCase Management

FacilitiesBusiness Office

Facility AuthorizationsProfessional Authorizations

ProfessionalFacilityRevenue managementDenial managementRetro-authorizationsModifications

Submission Verification Revenue Cycle

The “System”- Prior Authorizations

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Ambulatory Clinics




Submission

First Principle: Prior Authorization Submissions are Key

Prior Authorization issues & errors frequently occur at time of submission• Not submitted in time• Not ever done• Not properly documented• Wrong codes• Wrong sites of service

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First Principle: Prior Authorization Submissions are Highly Manual

Authorizations today require manual input

CAQH-CORE: Building Momentum: Moving forward with End-to-End Automation of Prior Authorization Processes (2019)

fax phone web portals

>95%

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Patient Access Delays

91% Physicians report delay in caredue to authorizations

Labor Time & Costs

$10.11 Cost per Manual Prior Authorization

Worsening Denials/Write-Offs

$25 Cost per Claim to Rework 50% Authorization Denials

Written Off

The High Cost of Prior Authorizations

CAQH 2018 Index Report | AMA Physician Survey | Becker’s Hospital Review | HFMA 2019 Authorization Workshop

16min Average Time per Manual Prior Authorization 1/3rd Physicians report significant adverse

outcome due to authorizations

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Highly Manual Exchange of Authorizations

fax forms

phone

web portals

Authorization Information

Patient DemoInsurance Member IDProvider Demo, NPIPayer

What?

Who?

ICD-10CPT, HCPCS, units/dosages

Where?POS codes, Sites of ServiceTax ID, NPI, Location

Why?Medical NecessityClinical Documentation

EHR

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Manual Documentation of Authorizations

fax forms

phone

web portals

EHR EHR

Professional Billing

Hospital Billing

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Authorization Informational Complexity

Who’s Paying?Health Plan vs IPA/MG

DOFRLOAs

Is Auth Required?PhoneOnline

Trial & ErrorConstant Change

How Do I Submit?Fax?

Web Portal?Phone?

What Info Needed?Clinical Documentation

Informational ComplexityWhere is it in the EHR?How to get Approved?

Sites of Service/Re-directs

“Tribal Knowledge”

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Where Authorization Can Go WrongAuthorization Information

Patient DemoInsurance Member IDProvider Demo, NPIPayer

What?

Who?

ICD-10CPT, HCPCS, units/dosages

Where?POS codes, Sites of ServiceTax ID, NPI, Location

Why?Medical NecessityClinical Documentation

Payer Antics• Lack of clear authorization rules• Fax Games

• “we never received the fax”• Auth responses to wrong fax numbers

• The Phone game• “no auth/pre-cert” by phone = denial for “no auth”

• The Bait and Switch• Redirect, change approvals

Internal controlProcess & Education

Countermeasures

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Ambulatory Clinics



SchedulingNotice of AdmissionsCase Management



PB/HBRevenue managementDenial managementAdjustmentsRetro-authorizationsModifications

Submission Verification/ Revenue Cycle

System-level Gaps in Communication(workflow & process)

Submission

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Common Workflow Communication Processes

• EHR work drivers • Telephone• Email• Message Center• Skype/IM• Referral Tracking system

Duplicate Manual EntryFragmented InfoPoor documentation

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Common Communication Problems(key challenges)

Ambulatory Clinics


Clearly Defined Roles & Responsibilities

Lack of VisibilityDuplicate Workflows

Facilities

Ambulatory Clinics

Lack of VisibilityPoor Feedback Loop

Business Office

Lack of real-time visibility across Authorization Life CycleFragmented information, Communication Gaps

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EHR Authorization Challenges

EHR• Lack of Interoperability• Legacy Data Models• Data Exchange & Interfacing Difficulty• Inability to Customize Workflows• Inability for Real-time Changes• Business Model Challenges

HL7 ADTX12 EDI 278APIs (ReST, FHIR)

21st Century Cures Act (2016)• Penalties for “Information Blocking”• API requirements

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Authorization Strategies & Tactics

PeopleProcessTechnology

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People• Authorization Subject Matter

Expertise• Information Complexity

Education & Training

• Complicated Human Behavior (positive & negative)

• Habits/Change ManagementTransparency & Accountability

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Process

• Clearly Define Roles & Responsibilities

• Standardize Workflows• Clean Transitions• Open Communication &

Collaboration• Meaningful Metrics• Feedback Loops

Continuous Iteration

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Technology

• Workflow Automation• Comprehensive Payer Coverage• Shared Visibility & Collaboration Tools• Real-time Insights & Rules

• Reduce Manual Work (not add)• Workflow-centric, Customizable• Rapidly Changeable

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Enterprise Authorization Platform

EHR

ONE place to submit, track, & manage the authorizations

Workflow Automation

Real-Time Reporting & Rules

Shared Visibility, Workflow Collaboration

Revenue Cycle Support, Business Rules

Standardization, Accountability, &Education

Bi-directional integration

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Prior Authorization Shared VisibilityEliminate duplicate work & errors

Ambulatory Clinics




Enterprise-wide visibility & collaboration

Facility, technical/ancillaryNotice of AdmissionsCase Management

Billing and codingDenial managementRetro-authorizationsModifications

E&M, procedures, surgery, meds, DMEs

E&M, procedures, surgery, meds, DMEsFacility, technical, ancillaries

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Prior Authorization Standardization & RulesSmarter, Cleaner Front-End Submissions

Ambulatory Clinics




Denials Management

• Service Code Templates• Business Rules • Crowd-sourced “tribal

knowledge database”

Workflow Collaboration

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Keck Medicine of USCTertiary-Referral Academic Medical Center• 3 Hospitals (Keck, Norris CCC, VHH - 619 beds)• 40 Outpatient locations • USC Care Medical Group – 938 MDs

CA Delegated Risk Payer MarketUnique Payer Fax Forms650+

15+ Payer Web Portals

Professional Facility Technical/Ancillaries Medications/Infusions Worker’s Comp Notice of Admission

All Service Types

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Keck Medicine of USC

Ambulatory Clinics

Centralized Pre-Arrival Facilities

Business Office

Notice of AdmissionsCase Management

Denial Management

Pilot & Phase 1 Phase 3

15 Specialty DivisionsProfessional/FacilityE&M Radiology, Infusions, Meds

10 Specialty Divisions6 Divisions pending approvalSurgery, procedures, etc.

Phase 2

Pilot time motion study

80%Reduction in manual staff processing time

Expansion

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Key Observations & Challenges

EHR Bi-Directional Integration

Clear Standard Processes

People/Change Management

EducationAccountability

CommunicationCollaborationAccountability

Reducing Manual Data Entry

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People

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Processes

Authorization Days Out(date of service – date of submission)

Real-Time Authorization Status

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Standardization & Education

Specific Instructions

Standardized Code Set Templates & Info

Chemo TACE regimen

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Payer Info & ProcessScheduling & Admitting Planning

(reduce cancellations)

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Final Thoughts

• Always Keep the Patient in Mind

• There are No Shortcuts in Healthcare

• Listen to People, Focus on Workflows

• Never Stop Improving

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Demo

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Steve Kim, MD, MBA, MSCECo-Founder

[email protected]

Voluware, Inc.5912 Bolsa Ave, Suite 201

Huntington Beach, CA 92649714.373.9333

®

Thank You!

mailto:[email protected]

1 prior authorization challenges & best practices · 2019-10-30 · 1 t his is. caham annual...

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