Insurer reviews get an automation boost

Driving the news: Electronic health records giant Epic tells Axios it's rolling out a new tool that immediately flags doctors if a procedure needs a health plan's check-off.

• The company is going live months ahead of a Jan. 1 deadline with data from UnitedHealthcare, Aetna and Network Health. Another 16 insurers are testing the system.
• Clinicians at Ochsner Health, Froedtert ThedaCare Health, Denver Health and Summit Health are among the first to gain access.

The big picture: Health systems now largely rely on their own lists of insurer requirements or seek them out when circumstances dictate. Automation means services not requiring pre-treatment review can begin immediately.

• Epic's move stems from a 2024 Centers for Medicare and Medicaid Services rule requiring insurers to provide data in a way that can be easily used to determine prior authorization requirements.
• "We are moving into this modern process of being able to remove humans out of the prior authorization request process," said Ryan Bohochik, who is part of Epic's product team.

Between the lines: Prior authorization remains a target for scrutiny amid complaints that government and industry streamlining efforts haven't eliminated hurdles for patients and doctors.

• Insurers turned down at least 1 in 8 requests for prior authorization last year in Medicare Advantage, Medicaid managed care and Affordable Care Act marketplaces, a new KFF analysis found.
• In May, CMS administrator Mehmet Oz announced the formation of a coalition of insurers, hospitals and health records companies to further refine the process for reviewing medical procedures.
• Health insurers say they've cut pre-treatment claim reviews by 11% in the past year after pledging to streamline requirements, Axios previously reported.

Reality check: Simply knowing when prior authorization is required doesn't eliminate having to go through the reviews or ensure that care will be delivered faster.

• The system is only as useful as the information the payers feed into it. Insurers have faced long-standing problems keeping provider directories and other basic information up to date, raising questions about whether flawed data could snag the streamlining efforts.
• Bohochik said Epic is extracting payers' most up-to-date information and will repeat queries as a patient moves closer to the point of service.

• Still, he acknowledged, "To have the answer be accurate, we have to make sure that the insurers are doing the work on their side."

Zoom in: The CMS-driven technology work is prompting insurers to take a harder look at prior authorization, said Sarah Dencker, vice president of care services at Network Health, a Wisconsin-based health plan.

• "When you're doing the work to have the technology work as intended, it's a time to open up your books and ask: Should this service continue to require prior authorization, or should it come off the prior auth list?"

What we're watching: The technology does not yet automate the documentation an insurer requires to establish medical necessity or submit that information for approval. Those are the next steps Epic and insurers are working to digitize.

• The bigger test will be whether the industry can move from instantly answering "Does this require prior authorization?" to actually automating the entire process — and whether that translates into less waiting for clinicians and patients.
• AI is expected to ultimately take on more of that work, by pulling required details from the medical record and reserving human review for only the toughest cases, Bohochik said.