Regence’s industry-leading online pre-authorization tools speed access to care, lower costs
Pre-authorizing products and services is one way to protect members from unnecessary or dangerous medical treatment. It also enables responsible management of health care costs for members and customers. However, pre-authorization (PA) can be frustrating for members and providers industry wide, in part because of the time they sometimes must wait for a decision.
To speed up the process, Regence implemented online tools in 2018 that have cut medical decision turnaround time in half – from six to three days. And 67% of PA requests are returned in two days. This electronic authorization process, or eAuth, accounts for nearly 45% of PA requests submitted for medical services.
On the pharmacy side, covermymeds, another digital solution, has streamlined the process for providers, enabling them to fill in all required information before submitting a request. This saves considerable time on the back and forth that often occurs with incomplete requests submitted by fax. Currently, 65% of all pharmacy PA requests are submitted through covermymeds.
Most medical requests -- 58% -- don’t even need PA, and these new online tools immediately alert providers if that’s the case so treatment can begin right away.
Automatic authorization allows near instant turnaround time
Another digital tool that’s helping smooth the process is AutoAuth, which allows providers to select applicable medical policy criteria and assess PA requests against that criteria. When criteria are met, the tool can return an approval decision in minutes, while a member waits in their doctor’s office.
“We are a leader among payers since the majority of our commercial medical policies are available in AutoAuth and more than 50% of our medical policies requiring PA are available for auto authorization,” said Heidi Kriz, manager of medical policy.
Data integration with electronic medical records on the horizon
These initial steps form the foundation to transform the member and provider experience in the area of PA. We are building toward integration with provider electronic medical records (EMR) where once PA is requested for a service, the tools could pull clinical data to validate clinical criteria have been met and deliver an automatic decision. This would also help providers initiate PA within the EMR and get instant feedback. This work is part of our larger effort to push the envelope on interoperability under the Davinci initiative. It’s a great example of what interoperability can do to improve the provider experience.
“Our ultimate endpoint is to eliminate the member from experiencing PA and make it less burdensome for providers, while protecting members and ensuring we continue to be good stewards of health care dollars,” Kriz said.