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Carle’s Preauthorization Process
The effort to obtain prior authorization for services can present a substantial burden for clinicians and staff. Dr. Robert Good discusses Carle's preauthorization process for Opioid addiction to improve best practice outcomes.
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Learn more about Robert G. Good, DO
Robert G. Good, DO
Robert G. Good, DO, is a practicing Internist in Mattoon, IL. Dr. Good graduated from Des Moines University College of Osteopathic Medicine in 1979 and has been in practice for 38 years. He currently practices at Carle Foundation Physician Services.Learn more about Robert G. Good, DO
Transcription:
Melanie Cole (Host): Healthcare providers often expend significant time and money on obtaining prior authorizations for services, and this effort can really present a substantial burden for clinicians and staff. My guest is Dr. Robert Good, he's the Chief Medical Officer of Carle Medical Management and Health Alliance Medical Plan. So Dr. Good, how does prior authorization affect timely patient treatment access? What's the connection there?
Dr. Robert Good, DO (Guest): Well hopefully it doesn't affect it at all. If everything works well, is done right, and the system works well, the information should be able to be put in, and we should be able to almost automatically get a response.
Melanie: So how can providers and health plans work together to improve the efficiency? Do you feel that there's a lot of work still to be done?
Dr. Good: If the system is mainly automated, that is there is an electronic way of inserting the information through an electronic portal, if that portal is connected to a computerized system that can analyze the data that's being put in, the results of the prior authorization ought to be almost immediate. And so the trick is if you've got an automated system, is to get as much information that is needed for decision making, to be put into that electronic portal right off the first time. If that can occur, particularly when it involves advanced imaging, most of these electronic systems will give an answer within seconds.
Melanie: So as long as you brought up technology, what technology can expedite the pre-authorization process and make it more seamless? Is this technology already out there?
Dr. Good: Right, and so we use a system in which the information is placed in, electronically it can determine if the key information is present. If it is, it will give almost an immediate result. If it isn't, it may push this to a person, a nurse at the other end who may review the information, and they may ask for additional information, or they may have to push it off to a medical director. If that happens, it takes more time. So the real key to this is utilizing - particularly within the Health Alliance System - is using the electronic portal, getting the right information in there, what's required to make a decision, so that the computer system can make an immediate result. Now that gets a little more difficult when we're talking about operative cases. So in that case, the electronics is not near as advanced, and so oftentimes that may have to get to a person, a nurse, and that may take up to twenty-four hours to get a result. We run about - within the Carle system - about 94% of all of our electronic submissions having a result within twenty-four hours. About 99% of some of the areas occur within one day. So there's some areas that are a lot more electronic than others.
Melanie: Do you think it's reasonable to ask patients to understand their role in managing healthcare costs which in turn can also expedite this process?
Dr. Good: It's really more about doing the right thing. The prior authorization process is really more about following best practice standards, and as the patient I would like to make sure that the physician or surgeon that's going to be working is following best practice. I think it should give the patient some reassurance that someone is doing some diligence to make sure that the system is working properly. Oftentimes we'll get a request for an imaging study that maybe could be done by a different imaging study, and that imaging request may actually be more expensive. So it's about doing the right thing. Yes, there is some cost reduction to this, but that's more about not duplicating services, and getting the right type of testing, or the right type of procedure the first time. So we really focus on what is best practice more than what the cost reduction would be. But should patients be involved in helping control cost? Yes, but it's really more about over-utilizing healthcare services, and I think that they should be aware of the potential harm that can happen when we over-utilize.
Melanie: So how do you balance the cost of containment with those treatment outcomes? If you're determining and rooting your decisions in clinical validity, how are you balancing that?
Dr. Good: Well we believe that doing the right thing is really what we want to do, and that's our value. It's in providing the best service with the best practice as documented by well-defined outcomes that's evidence-based in nature, and if we can do that, that's the best care we can provide for the patient.
Melanie: Is there a way to evaluate the impact on outcomes?
Dr. Good: Well we do. I mean obviously there is a cost to going through a prior authorization process, and so you want to make sure from a business perspective that there's a return on that investment, and indeed that certainly happens. But the primary mission here is really maintain the highest quality care that we can.
Melanie: Tell us about Carle's prior authorization techniques that improve your best practice outcomes and the Health Alliance Insurance Company's process.
Dr. Good: Well again, we use an electronic type of system. This computer system actually has predictive analytics attached to it, so if a physician who is placing, or his staff is placing in a portal an application, let's just say for an MRI scan, and a high percentage of the time that data that's submitted is meeting criteria to have that scan completed, and it gets approved. Over time the computer starts to learn particular provider, so if they do really well, they start to learn that, "Hey this person generally does it well," and so the threshold of the information that needs to be there may start to decrease a little bit, and the approval rate is easier. By the same token, somebody who's having difficulty in getting the right procedure, or getting the right information into that electronic system, the computer will also analyze that and start to understand that this provider maybe is not getting the information in adequately every time, and it kind of raises the threshold some. So the analytic system will really help the provider who is making the right type of decisions each time in order to expedite this. We also have the ability to have true peers, so in highly surgical specialties and other types of high specialties, true peers to be able to evaluate and assess. Now as we get into specialties, oftentimes there's very unusual cases, and those types of cases require a lot of medical judgment and that judgment ought to come from a true peer, somebody in the same specialty. So we were able to utilize that as a mechanism. We also do our own appeals process. So if there is a denial initially, our Health Alliance Medical directors will review the appeal process, look at the best evidence data, and make it a little closer to home as far as the final decision is concerned. So I think in those kinds of processes, we really look toward what's the practice that's out there, and how can we use the electronic system to make this as quick and as non-invasive into a physician's practice as possible.
Melanie: Do you see any barriers to patient care access as far as patients and providers who don't know, or maybe are not aware of what treatments they can and can't access?
Dr. Good: Yeah, I think if there is a provider office that doesn't truly understand the 'why,' why we're trying to do this, and the process that we need to go through in order to get the right information, that can slow down the process. So if the provider's office is using a lot of faxes instead of using the electronic portal, if they are always putting everything in urgent rather than going through the electronic portal; those are things that can slow down the process and might create some concerns in a surgical procedure, let's say. Most of the time, the majority of procedures are elective, there's time to do this. We set standards of forty-eight hours or seventy-two hours for more urgent- almost immediately for urgent requests, otherwise we give up to fourteen days to make a decision depending upon the complications of the procedure, and that type of thing. So there's time barriers that we limit ourselves to when we have to be able to make decisions.
Melanie: So in summary, Dr. Good, tell other physicians what you'd like them to know about Carle's pre-authorization techniques to improve their own best practice outcomes.
Dr. Good: Well I think the first thing is to make sure that the information is available for the staff to get the information into the portal, so it's very clear what the request is and the 'why' for the request. So the data and information to be able to make a decision is placed into that portal so that the electronic system can do its thing, and if that can't make a decision, then the first line of reviewers can make a decision. That's the first step and will make this a whole lot easier if they could do that. If there's a need for an urgent request, then a phone call to get that urgent request approved would be appropriate, and that generally will result in a physician-to-physician discussion, and generally that should happen relatively quickly. I think those are kind of the key things. It's just the first time that the information is placed in, it needs to be as accurate and complete as possible.
Melanie: Thank you so much, Dr. Good, for being with us today. It's really great information. You're listening to Expert Insights with Carle Foundation Hospital. For a listing of Carle providers and to view Carle's sponsored educational activities, please visit www.CarleConnect.com. That's www.CarleConnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole.
Melanie Cole (Host): Healthcare providers often expend significant time and money on obtaining prior authorizations for services, and this effort can really present a substantial burden for clinicians and staff. My guest is Dr. Robert Good, he's the Chief Medical Officer of Carle Medical Management and Health Alliance Medical Plan. So Dr. Good, how does prior authorization affect timely patient treatment access? What's the connection there?
Dr. Robert Good, DO (Guest): Well hopefully it doesn't affect it at all. If everything works well, is done right, and the system works well, the information should be able to be put in, and we should be able to almost automatically get a response.
Melanie: So how can providers and health plans work together to improve the efficiency? Do you feel that there's a lot of work still to be done?
Dr. Good: If the system is mainly automated, that is there is an electronic way of inserting the information through an electronic portal, if that portal is connected to a computerized system that can analyze the data that's being put in, the results of the prior authorization ought to be almost immediate. And so the trick is if you've got an automated system, is to get as much information that is needed for decision making, to be put into that electronic portal right off the first time. If that can occur, particularly when it involves advanced imaging, most of these electronic systems will give an answer within seconds.
Melanie: So as long as you brought up technology, what technology can expedite the pre-authorization process and make it more seamless? Is this technology already out there?
Dr. Good: Right, and so we use a system in which the information is placed in, electronically it can determine if the key information is present. If it is, it will give almost an immediate result. If it isn't, it may push this to a person, a nurse at the other end who may review the information, and they may ask for additional information, or they may have to push it off to a medical director. If that happens, it takes more time. So the real key to this is utilizing - particularly within the Health Alliance System - is using the electronic portal, getting the right information in there, what's required to make a decision, so that the computer system can make an immediate result. Now that gets a little more difficult when we're talking about operative cases. So in that case, the electronics is not near as advanced, and so oftentimes that may have to get to a person, a nurse, and that may take up to twenty-four hours to get a result. We run about - within the Carle system - about 94% of all of our electronic submissions having a result within twenty-four hours. About 99% of some of the areas occur within one day. So there's some areas that are a lot more electronic than others.
Melanie: Do you think it's reasonable to ask patients to understand their role in managing healthcare costs which in turn can also expedite this process?
Dr. Good: It's really more about doing the right thing. The prior authorization process is really more about following best practice standards, and as the patient I would like to make sure that the physician or surgeon that's going to be working is following best practice. I think it should give the patient some reassurance that someone is doing some diligence to make sure that the system is working properly. Oftentimes we'll get a request for an imaging study that maybe could be done by a different imaging study, and that imaging request may actually be more expensive. So it's about doing the right thing. Yes, there is some cost reduction to this, but that's more about not duplicating services, and getting the right type of testing, or the right type of procedure the first time. So we really focus on what is best practice more than what the cost reduction would be. But should patients be involved in helping control cost? Yes, but it's really more about over-utilizing healthcare services, and I think that they should be aware of the potential harm that can happen when we over-utilize.
Melanie: So how do you balance the cost of containment with those treatment outcomes? If you're determining and rooting your decisions in clinical validity, how are you balancing that?
Dr. Good: Well we believe that doing the right thing is really what we want to do, and that's our value. It's in providing the best service with the best practice as documented by well-defined outcomes that's evidence-based in nature, and if we can do that, that's the best care we can provide for the patient.
Melanie: Is there a way to evaluate the impact on outcomes?
Dr. Good: Well we do. I mean obviously there is a cost to going through a prior authorization process, and so you want to make sure from a business perspective that there's a return on that investment, and indeed that certainly happens. But the primary mission here is really maintain the highest quality care that we can.
Melanie: Tell us about Carle's prior authorization techniques that improve your best practice outcomes and the Health Alliance Insurance Company's process.
Dr. Good: Well again, we use an electronic type of system. This computer system actually has predictive analytics attached to it, so if a physician who is placing, or his staff is placing in a portal an application, let's just say for an MRI scan, and a high percentage of the time that data that's submitted is meeting criteria to have that scan completed, and it gets approved. Over time the computer starts to learn particular provider, so if they do really well, they start to learn that, "Hey this person generally does it well," and so the threshold of the information that needs to be there may start to decrease a little bit, and the approval rate is easier. By the same token, somebody who's having difficulty in getting the right procedure, or getting the right information into that electronic system, the computer will also analyze that and start to understand that this provider maybe is not getting the information in adequately every time, and it kind of raises the threshold some. So the analytic system will really help the provider who is making the right type of decisions each time in order to expedite this. We also have the ability to have true peers, so in highly surgical specialties and other types of high specialties, true peers to be able to evaluate and assess. Now as we get into specialties, oftentimes there's very unusual cases, and those types of cases require a lot of medical judgment and that judgment ought to come from a true peer, somebody in the same specialty. So we were able to utilize that as a mechanism. We also do our own appeals process. So if there is a denial initially, our Health Alliance Medical directors will review the appeal process, look at the best evidence data, and make it a little closer to home as far as the final decision is concerned. So I think in those kinds of processes, we really look toward what's the practice that's out there, and how can we use the electronic system to make this as quick and as non-invasive into a physician's practice as possible.
Melanie: Do you see any barriers to patient care access as far as patients and providers who don't know, or maybe are not aware of what treatments they can and can't access?
Dr. Good: Yeah, I think if there is a provider office that doesn't truly understand the 'why,' why we're trying to do this, and the process that we need to go through in order to get the right information, that can slow down the process. So if the provider's office is using a lot of faxes instead of using the electronic portal, if they are always putting everything in urgent rather than going through the electronic portal; those are things that can slow down the process and might create some concerns in a surgical procedure, let's say. Most of the time, the majority of procedures are elective, there's time to do this. We set standards of forty-eight hours or seventy-two hours for more urgent- almost immediately for urgent requests, otherwise we give up to fourteen days to make a decision depending upon the complications of the procedure, and that type of thing. So there's time barriers that we limit ourselves to when we have to be able to make decisions.
Melanie: So in summary, Dr. Good, tell other physicians what you'd like them to know about Carle's pre-authorization techniques to improve their own best practice outcomes.
Dr. Good: Well I think the first thing is to make sure that the information is available for the staff to get the information into the portal, so it's very clear what the request is and the 'why' for the request. So the data and information to be able to make a decision is placed into that portal so that the electronic system can do its thing, and if that can't make a decision, then the first line of reviewers can make a decision. That's the first step and will make this a whole lot easier if they could do that. If there's a need for an urgent request, then a phone call to get that urgent request approved would be appropriate, and that generally will result in a physician-to-physician discussion, and generally that should happen relatively quickly. I think those are kind of the key things. It's just the first time that the information is placed in, it needs to be as accurate and complete as possible.
Melanie: Thank you so much, Dr. Good, for being with us today. It's really great information. You're listening to Expert Insights with Carle Foundation Hospital. For a listing of Carle providers and to view Carle's sponsored educational activities, please visit www.CarleConnect.com. That's www.CarleConnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole.