The Problem

Read Time: 3 Minutes

Preauthorization is the process by which a Payer determines whether it will provide coverage for a future service (drug, imaging study, surgery, etc). Each Payer provides a list of the requirements for each condition that must be met to obtain approval. The whole process is simple in theory, but it has proven to be complex in practice.

Because of perceived problems around preauthorization, the Centers for Medicare and Medicaid Services (CMS) has issued a mandate (CMS-0057) that must be met in the next few years by Providers and Payers. The goal is to improve patient care by removing some of the barriers that Patients experience in their care.

If It Were an Ideal World

In theory preauthorization should not be a problem. There are 4 core validations to be made:

1

Does the Patient have a contraindication, making the request unsuitable?

2

Does the Patient have an approved indication?

3

Is the indication significant (based on severity, stage or some other measure)?

4

Have alternative therapies that may be cheaper or less hazardous been tried?

As a rule, this can be stated as: IF the Patient does not have a contraindication AND if the Patient has an approved indication AND if the condition is significant enough AND if other options have failed, THEN the request should be approved ELSE denied.

This can be depicted in BPMN as:

Figure 1: BPMN Template for Pre-Authorization.

This is all very straightforward. So why are there perceived problems?

Nothing Is Perfect

Unfortunately, assumptions about an ideal world tend to fail in the real world. Failures may be due to a range of factors, such as:

Potential Patient-related issues:

Having problems with confirming identity.
Not being enrolled with payer.
Claiming coverage under a relative’s name.
Having a fraudulent intent.
Having an uncertain diagnosis.

Potential Provider related issues:

Provider not being enrolled with payer.
Submission of incomplete information.
Request for coverage of a service that is essentially research.
Request for coverage of a service that has some evidence but not yet “standard of care”.
Inadequate trial of alternative therapies that may be cheaper or safer.
Request for coverage of a service that is inappropriate for the patient.
Repeat request from multiple providers.

Potential Payer related issues:

Insufficient number of reviewing personnel.
Poorly trained personnel.
“No, no, no” directives, with reviewers given incentives to deny everything.
“Delay, delay, delay” directives, with barriers at all stages, hoping that the Provider gives up or the Patient no longer needs it (e.g. dies).
Use of post-facto information to deny a request.
Use of complicated and non-transparent processes.

While denial of a request can always be appealed, the whole process of responding to a denial is a major pain point for Providers. Failing to appeal may mean that a Patient does not get the care that the Provider believes is necessary. On the other hand, appealing a denial can be a long and painful experience. The denial process is not standardized between Payers and can appear to be somewhat arbitrary. Providers often:

Lack sufficient personnel to manage the paperwork.
Lack office processes to track an appeal’s status.
Lack information about what the Payer is thinking.

A Provider can always refer denials to a third party to manage, but the costs of doing so may become an issue when reimbursements are low. This leaves many Providers feeling trapped by a system that does not listen to them.

What Might Be an Effective Solution?

To solve these problems there is a need for:

Improved Patient identification.
Complete and accessible Patient health records.
Improved communications between Providers, Payers and Patients.
Transparency.
A level playing field between stakeholders.
A monitoring mechanism to ensure compliance.
A means of orchestrating the entire patient journey.

Whether CMS will be able to provide an effective solution will depend on several factors, including any unexpected consequences of the mandates. The goals are commendable, and now it is up to the stakeholders to work together to make it a success. In the next part we will discuss how BPM+ can provide solutions to these problems.