American Hospital Association urges caution with prior auth automation

AHA requesting CMS agencies to pilot technology and workflows prior to implementing regulations

The American Hospital Association has submitted a letter to Micky Tripathi, National Coordinator for Health Information Technology, urging caution in the approach to streamlining the prior authorization process.

While the AHA supports the removal of inappropriate barriers to care, it urges the Office of the National Coordinator and CMS to pilot the technologies and workflows described in the rule prior to taking any regulatory steps, including certification or codification of standards to minimize unintended consequences, such as inadvertent increase in costs or burden in the health care system.

Standardized electronic prior authorization transactions have the potential to save patients, providers, and utilization review entities significant time and resources and can speed up the care delivery process, but the AHA says any changes need to be approached judiciously.

“Any substantial change in the technology and/or standards used in health care information exchange should be sufficiently tested to ensure functionality, analyzed to establish projected return on investment, and incorporated according to an appropriate glide path to minimize systematic disruption,” the letter reads in part.

The AHA supports an automated prior auth process that integrates with clinicians’ EHR workflow, and that using the EHR for submission and processing would allow physicians to use the information during treatment planning and creates the potential for meaningful, real-time access to the data.

“Robust pilot testing would not only ensure that the transaction is truly ready for real-world usage, but also provide important data on the beneficial improvements achieved through usage of the transaction (e.g. reduced delays, elimination of administrative burden). Proof of adequate return on investment will inevitably be critical to convincing providers and plans to undertake the significant technology investments and workflow adjustments needed to utilize the IGs,” the letter reads.

The organization points out that there is currently no national standard method for attaching clinical data to claims, which could lead to significant problems.

In addition to standardizing the prior auth process, the AHA also says there should be:

  • Increased oversight to ensure that health plans are not denying medically appropriate care;
  • Controls over the application of prior authorizations to ensure that it is only applied to services with high costs or a history of overutilization; and
  • Requirements that plans process prior authorizations at all times, rather than only during standard business hours.