Healthcare Needs a Data-Driven Approach to Reform Prior Auths

Contributed by Andrew Bess , EVP and Chief Client Officer at Ensemble Health Partners

Prior authorization processes need to be streamlined — but recent initiatives haven’t gone far enough. Recently, major insurers like Humana and Cigna have taken steps toward reform. These efforts, while outwardly commendable, often miss the mark in addressing the core issues faced by hospitals and patients alike.?

Reform is in practice, but not yet perfect.?

Humana’s CEO, Jim Rechtin, has articulated a clear vision for reducing the friction in prior authorization through increased automation. By aiming to boost the percentage of automatically approved requests, Humana seeks to minimize delays and ensure timely access to necessary care. This approach underscores the importance of leveraging technology to enhance efficiency and reduce administrative burdens.?

On the other hand, Cigna’s recent policy change — which eliminated 25% of the codes requiring pre-authorization — appears less impactful upon closer scrutiny. Efforts to streamline the patient and provider experience are worthy of acknowledgment. In practice, however, based on our client data, these specific codes account for only 1% of the actual prior authorization volume.??

A critical gap exists between policy intentions and real-world outcomes: The top CPT codes by volume that require prior authorization in hospitals remain largely unaddressed, suggesting that insurers may not be fully attuned to the practical challenges faced by healthcare providers.? ?

After all, there’s a common goal to keep in mind — patient care. Pre-authorization requirements must remain transactional in nature, without ever impeding a provider’s ability to establish a plan of care that is focused on addressing the patient’s overall health.?

Lead with the right data to solve the challenges.?

This is where data has a role to play. To truly streamline the prior authorization process, insurers must adopt a data-driven approach. By analyzing provider volumes and identifying the most burdensome codes, insurers can tailor their policies to better align with the needs of the healthcare system.??

An analytical approach:? ?

• Minimizes friction between payers and providers?

• Fosters prompt payments?

• Reduces administrative complexities?

Advocacy is also critical — healthcare providers must actively engage with state and federal lawmakers, as well as Managed Care executives, to advocate for fair and prompt compensation. But because healthcare providers are strapped for cash, struggling with minimal or no margins, putting resources to this largely allows insurance companies to carry and own the narrative.?

We’re going to keep doing what needs to be done.?

At Ensemble Health Partners, we understand just how important healthcare providers are to their patients and the communities — but we also know that care can’t be delivered in a vacuum or without the proper resources. Our team champions the rights of providers and helps them get the compensation they deserve.??

While the recent prior authorization efforts by Humana and Cigna represent steps in the right direction, there is a pressing need for a more targeted and cohesive data-driven reform discussion, especially by the parties most impacted — patients and providers. ? ?

By leveraging data analytics and fostering collaboration between payers, providers and policymakers, our industry can create a more equitable prior authorization process that keeps patient care as its focus. Healthcare offers no shortage of challenges; let’s look to the resources and tools at our disposal to better and more efficiently address these together.?

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