Simplifying Prior Authorization While Protecting Patient Safety

Anthem recently joined AHIP and other leading health plans in publicly committing to a set of actions that streamline, simplify, and reduce prior authorization. These actions aim to help consumers get faster, more seamless access to care while reducing the administrative burden on care providers. 

What Is Prior Authorization?

Employers, individuals, and government entities hire health plans to manage the administrative work of health insurance and related services. Reviewing medical procedures, services, and medications for appropriate use through prior authorization is a fundamental piece of that work. We continually seek ways to streamline prior authorization’s administrative steps while preserving the ability to protect patient safety and help keep healthcare costs under control.

Enhancing Patient Safety And Minimizing Delays

Prior authorization helps protect patient safety by ensuring their care is essential for a patient’s health and supported by evidence-based standards and clinical guidelines. When a health plan member receives care from multiple providers, prior authorization helps make sure that care is coordinated, safe, and effective. It double-checks proposed treatment for medical and medication errors as well as use of unproven care. It catches prescriptions for devices or medications that are not approved by the United States Food and Drug Administration (FDA) and monitors medications that have a high potential for misuse. These steps — from helping to avoid negative medication interactions to ensuring that conservative medical treatments take place before jumping ahead to surgery — put safeguards in place and use data from hundreds of thousands of similar procedures and prescriptions to assure best practices. 

Anthem also works to make prior authorization happen faster. Most prior authorization requests are submitted by care providers to health plans via phone, mail, or fax, which adds considerable processing time. Our company has invested in digital solutions that enable and encourage care providers to use real-time prior authorization submission and workflow services.

In our continuous effort to accelerate prior authorization reviews, we are harnessing the power of artificial intelligence (AI) to speed up approvals. This helps to enable the prompt scheduling of needed services and decreases confusion and frustration. At Anthem, the majority of prior authorization requests that come through our portals are approved in real time, and most are approved in less than 72 hours. Emergency treatment of any kind never requires prior authorization, and our members can access emergency services 24/7 at any facility. Additionally, Anthem does not use AI to automate denials of prior authorization requests. Only licensed clinicians determine that a prior authorization does not meet criteria for approval. 

Partnerships With Healthcare Providers Reduce Or Eliminate The Need For Prior Authorization

We continually seek ways to improve our partnerships with care providers. We have invested in digital tools and technology to make it easier and less time-consuming to submit prior authorization requests, and we are streamlining our own clinical review processes to improve turnaround times. As a result, our care providers and members can expect faster prior authorization approvals and delivery of evidence-based care.

Anthem helps care providers adopt innovative secure data exchange platforms that make it possible for health plans and care providers to securely exchange real-time information about a patient’s conditions. Not only does this partnership help patients get timely care, but it also cuts down on the administrative cost and burden for both care providers and health plans. Anthem care provider partners have commended the efficiency and quickness of processing prior authorizations, and we continue to onboard more care providers in this program.

For certain large, high-performing medical groups, the Anthem Prior Authorization Pass (PA Pass) program — similar to commonly known “gold card” programs exempting providers from prior authorization requirements — waives approximately 400 outpatient procedure codes. Care providers qualify for the program when they are in value-based payment arrangements with our health plans and meet specific performance criteria. Currently, 16 health systems in seven states representing thousands of physicians qualify for PA Pass. 

For smaller medical groups, the Prior Authorization Optimization (PAO) program allows automatic and real-time approval for approximately 250 outpatient procedure codes when the provider submits the authorization request electronically.

Care providers that adopt electronic prior authorization through our provider portals and select electronic medical records (EMRs) also benefit from two-way communication with clinicians at Anthem, as well as cleaner and more complete authorization information leading to quicker clinical determinations. Furthermore, care providers can access all authorization data in a single location and quickly check the status of any authorization, even if it was not initially submitted electronically.

Where prior authorization is needed, digital technologies have made it significantly faster and more efficient. One study found care providers save an average of 11 minutes for each request when using electronic prior authorization, translating to more time with their patients. The study also estimated that by just conducting prior authorization via electronic clinical records, the healthcare industry could potentially save $449 million per year because of reduced administrative cost and burden. It is important to highlight that these savings are administrative, as Anthem plans do not use costs as a factor when making prior authorization determinations.  

A Future Focused On Quality, Accessible, And Affordable Care 

As it evolves, prior authorization remains an essential tool for promoting high-quality care. By continuously reevaluating and improving upon traditional models of care enablement, we aim to promote a health system that is more responsive to the needs of patients and care providers. Our focus on modernizing prior authorization, embracing digital solutions, and investing in automation that seamlessly integrates into electronic health records represents a commitment toward creating a patient-centered healthcare experience that is safer, more efficient, and accessible.