September 23, 2022

Prior Authorization Series: Part 4 of 6

We Need to Streamline Eligibility Verification “STAT”

Patient coverage and benefits are a cornerstone of health insurance. However, given the wide variety of health plans, confirming patient eligibility often comes at the cost of money and time for the provider, which impacts productivity. On average, the manual approval process to verify patient eligibility takes up to 12.64 minutes. What makes matters worse is that eligibility verification is embedded within the pre-certification workflow, making it a non-negotiable requirement that can't be circumvented. 

Nearly all health plans incorporate some version of eligibility verification (a.k.a. prior authorization) in their operations to ensure their patients are receiving the appropriate health benefits and services. In practice, before a provider can administer select services, a precertification process must be completed by the patient's corresponding payer to verify he or she is covered. This is an important step in ensuring the patient has coverage and will not be in for a nasty bill later on.

Unfortunately, the process is far from streamlined due to a portion of the prior authorization (PA) workflow still relying on a manual approval process. While some payers provide electronic patient eligibility checks in their portal that reduce the verification process to under two minutes, the process is still less than optimal as it requires the practice staff to access an external application outside their clinical workflow. Given the many payers a provider may serve, electronic patient eligibility checks often give way to a new burden of needing to access several different portals to complete a single PA. 

Fortunately, the advent of coverage requirements discovery (CRD) has presented a solution to this problem.

What Is CRD or ‘Coverage Requirements Discovery’?

The CRD is a protocol within the electronic PA workflow that facilitates calls between electronic health records (EHRs) and the payers using clinical decision support (CDS) and CDS services. When utilized, it provides information on coverage requirements to providers while patient care decisions are in progress. This enables provider staff to make more informed decisions and meet the requirements of their patient’s insurance coverage. 

So how is this communication made possible? The answer is CDS Hooks.

Let's Get Hook(ed) on CDS!

CDS Hooks are an API that builds on the FHIR core specification, allowing EHRs to automatically trigger external clinical decision support services (CDSS) based on events that occur during application use. In layman's terms, CDS hooks enable data exchange between payers and providers, facilitating the communication needed to evaluate and approve patient coverage in real-time.

With CDS hooks, eligibility practices like prior authorization can be properly optimized, along with other precertification requirements like the physician’s network participation. 

This function assists providers in making informed decisions by providing them with information on their patient’s condition, treatment options, and the forms needed to be completed to facilitate their care. The strategic use of CDS hooks will allow clinicians to quickly develop more patient-centered care plans and assist the PA process by disclosing critical administrative and clinical requirements.

The exchange of all this information will be received via CDS notifications that supply relevant information (or ‘card’ for FHIR users) to the EHR. To be specific, there are three types of cards one must be aware of:

1. Information card: Communicates information about a patient’s health plan coverage or benefit and the PA requirements involved.

2. Suggestion card: Provides relevant suggestions about a patient’s condition and the treatment options available.

3. App link card: Presents links to reference materials and forms that must be completed.

How Can Payers and Providers Leverage the CRD Framework and CDS Hooks to Improve the PA Process?

CRD enables providers to uncover, in real-time, specific payer requirements that affect whether a service or device prescribed for a patient is covered by their health plan. The discovery process may be based on:

• The health plan’s requirements for prior auth (including CPT or HCPCS for which they review for medical necessity)

• The status of the patient’s enrollment with the health plan

• The participation of the referring and rendering providers and whether Gold Card privilege is present

The following use case is an example of how CRD can be used to facilitate an efficient approval workflow:

Mrs. Smith has complained of a persistent headache for more than a week. Her physician, Dr. Jones, would like to order a CT scan. However, prior to ordering, Dr. Jones would like to see the coverage requirements of Mrs. Smith’s plan to see if a CT scan is covered. Upon her order for the CT, she receives a card notification that a CT scan of the head requires prior authorization. The card contains additional instructions for him to follow the link to the precertification questionnaire, which is included in the card.

The above use cases demonstrate the important role event-trigger mechanics play in facilitating a streamlined workflow. In the case of Mrs. Smith, when her CT scan was ordered it returned an output in the form of a card. This card provided information to her clinician about the coverage of her service along with the steps needed to contact her payer. Her payer’s response to a CDS hook request for coverage determination may include any of the following:

• An indication that no coverage requirements exist for the ordered therapy.

• A full list of services, documents, templates, and/or rules that do apply.

• A user interface (UI) to retrieve specific documents such as forms or templates.

• The ability for the clinician to launch an application to further investigate or complete the requirements.

Regardless of which response is given, the instant notification system enabled by CDS Hooks allows clinicians and payers to share and process data and make decisions, seamlessly. For example, if a physician sends a prescription to a plan for approval, the system can respond straight away with an alternative drug recommendation that can save money or maybe even provide a better patient outcome. Alerts also can suggest helpful apps, like one that uses information in a patient's EHR to adjust their dosage. Clinicians could actually be supported with the relevant evidence-based information they need…when they need it.

By invoking a CDS service, clinicians can better understand the patient’s specific coverage and forgo the need to perform external patient eligibility checks to determine whether patients are eligible for the services being ordered. This eliminates time from the provider’s work, ensures more appropriate (cost-effective and high-quality) therapy is ordered, and critically, ensures that the PA process is unencumbered by inaccurate or incomplete information for the request. Essentially, CDS Hooks enables multiple different backend services all at the same time and integrates or aggregates results, assisting clinicians in their decision-making process.

Smile CDR Is Leading the Way with CDS Hooks

CDS Hooks API is a core service that’s built into Smile CDR’s Prior Authorization Integration (PAI) Solution. Smile’s PAI enables payers to leverage the FHIR interoperability framework to support PAs in a highly responsive workflow that significantly reduces low-value manual work.

Smile CDR offers both payers and providers the flexibility to scale-up functionality as and when required. As the first FHIR server to integrate support for CDS Hooks, Smile CDR is a valuable partner for payers and providers looking to optimize care through evidence-based clinical decision support.

The Bottom Line

The administrative strain of prior authorization pervades healthcare delivery. Thanks to FHIR, open standards APIs such as CDS Hooks can deliver meaningful impact through data sharing by eliminating the need for manual administrative tasks such as verifying patient benefits and coverage. When implemented properly, clinicians can obtain immediate information more accurately. This change has the potential to transform clinical healthcare - reducing the burden on payers and providers, ensuring service eligibility, and ultimately, delivering better health outcomes for members.

Interested in learning more about Smile’s Prior Authorization Solution? Click here!

To continue learning about the Prior Authorization Series, read our blogs:

Part 1: Why the CMS Prior Authorization Rule Is a Win for Providers and Payers
Part 2: A Mutual Burden for Providers and Payers and How Interoperability Can Facilitate Change
Part 3: Breaking Down CMS Rule: Open Standards Bring Healthcare Out of the Stone Age
Part 4: How CDS Hooks Will Break Down Data Silos in Healthcare
Part 5: Harnessing the Real Power of Data Interoperability
Part 6: Coming Soon…