The prior authorization process, in theory, is designed to help payers get their members the care they need while keeping premiums down and preventing unnecessary procedures. However, due to long response times, complicated processes for filing, and a lack of transparency, providers, regulators, and members are looking for a change. These problems prompted the Centers for Medicare and Medicaid to propose CMS-0057, new guidelines which task payers with overhauling their authorization process to make it quicker and more transparent. But this is no small feat, given the volume of requests that come in from members and sheer complexity of administrative systems.
The prior authorization process, in theory, is designed to help payers get their members the care they need while keeping premiums down and preventing unnecessary procedures. However, due to long response times, complicated processes for filing, and a lack of transparency, providers, regulators, and members are looking for a change. These problems prompted the Centers for Medicare and Medicaid to propose CMS-0057, new guidelines which task payers with overhauling their authorization process to make it quicker and more transparent. But this is no small feat, given the volume of requests that come in from members and sheer complexity of administrative systems.
In this episode of Transformation @ Work, we examine how payers can begin to lay the groundwork to address these changes, and get ahead of requirements by digitalizing the prior authorization process.
Key Insights
03:25: Examining the current prior authorization process from the payer’s perspective
05:45: Flipping the script: examining prior authorizations – and their pitfalls – from the member’s point of view
08:04: Pain points in the authorization process for payers, members, and providers
10:13: Breaking down the proposed changes within CMS-0057 and how they impact payers
13:21: Potential challenges in implementation for payers seeking to comply with CMS-0057
16:06: How digital tools can help payers lay the groundwork for a better prior authorization process
18:54: The role a qualified technology partner can play in helping payers get ahead of proposed guidelines and stay compliant
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