Most public and private health plans rely on prior authorization as a cost containment strategy when determining coverage for a prescribed procedure or service. Yet most practitioners regard the prior authorization process as a burden, according to a survey by the American Medical Association (AMA). These 2019 statistics show that 86% of physicians report spending an average of 14.4 hours a week either managing prior authorizations or dedicating staff exclusively to the process.[1] But, while 96% of medical claims are submitted electronically, 87% of prior authorizations are still completed using manual processes, raising an obvious question – why?[2]
The reasons are multifaceted, but they include the lack of an attachment standard to support the exchange of medical documentation between payers and providers; inconsistent use of data standards; and lack of both vendor support and provider awareness. Payers do not have access to the medical notes, test results, or patient histories stored in electronic health records (EHRs); meaning a solution is needed to facilitate the exchange of that data between providers and payers more efficiently.
Enter the Da Vinci project, a collaborative effort between HL7 and industry partners to accelerate the adoption of the Fast Healthcare Interoperability Resources (FHIR) standard. The goal of the Da Vinci project, according to HL7 International, is “to help payers and providers to positively impact clinical, quality, cost, and care management outcomes,” by supporting the clinician and payer workflows needed for efficient information interoperability. To accomplish this goal, Da Vinci is currently testing use cases that support prior authorization activities and the exchange of clinical information.
Da Vinci makes full use of the FHIR standard, which establishes common building blocks to represent health data in clinical care, financial transactions, health care research, public health, workflow management, and more. FHIR can be used in a variety of applications, including mobile apps, cloud communications, and EHRs; and as a standardized structure for healthcare information that can be interpreted by any system, no matter where the information originated.
Reducing provider burden through the automation of prior authorization processes has long been a priority in Medicare payment policy – first, as a provision of the 2014 Protecting Access to Medicare Act’s Appropriate Use Criteria (AUC) requirements, and again in a Notice of Proposed Rulemaking (NPRN) issued December 10, 2020. While unresolved technical and workflow challenges led to repeated delays in the implementation of AUC regulations, solutions developed by the Da Vinci project and specified in the NPRN could reliably automate prior authorization processes and significantly reduce provider burden.
The proposed rule requires that care plans managed by Medicaid and the Children’s Health Insurance Program (CHIP); state Medicaid and CHIP fee-for-service programs; and Qualified Health Plan issuers on federally facilitated health exchanges implement a Provider Access Application Programming Interface (API) for payer-to-provider data sharing of claim and encounter data compliant with both HL7 and FHIR. Prior authorization workflows between payer and provider would ultimately be supported through a Document Requirements Lookup Service (DRLS) API conformant with the following Da Vinci Implementation Guides (IGs):
- HL7 FHIR Da Vinci Coverage Requirements Discovery (CRD)
- Da Vinci Documentation Templates and Rules (DTR)
- Prior Authorization Support (PAS)
The proposed rule was initially finalized on January 15, 2021. Over 250 comments were received during a brief 17-day comment period. While commenters were generally supportive of automating prior authorization processes, they did express concerns regarding the maturity of the IGs specified in the proposed rule; the exclusion of Medicare Advantage plans and Medicare Fee for Service plans; and the lack of clarity around a HIPAA compliant attachment standard. As the final rule falls under President Biden’s January 20 memorandum for Regulatory Freeze Pending Review, the rule has been returned to proposed status. CMS will be reviewing and potentially updating the proposed rule in February 2021.
