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What are the new CMS rules regarding prior authorization? Why is my prior authorization denied? What are the benefits of electronic health information exchange? Our guest is Population Health Chief at Ochsner Health This is Dr. Philip Orabetz. Hosted by AMA Chief Experience Officer Todd Unger.
speaker
- Philip Oravetz, MD, Chief Population Health Officer, Ochsner Health
Unger: Hello. Welcome to AMA Update videos and podcasts. Today we'll talk about an innovative way one health system uses its EHR to save time on pre-authorizations. Here, Dr. Philip Oravetz, population health chief at Ochsner Health in New Orleans, tells us all about it. I'm Todd Unger, Chief Experience Officer at His AMA in Chicago. Dr. Orabetz, welcome.
Dr. Orabetz: Thank you, Todd. It's an honor to be here this afternoon to talk about some really innovative research that we're doing here at Ochsner.
Unger: absolutely. Well, let's start with a little background. In recent years, advocacy efforts at the state and federal level have reduced the burden of prior authorization. I've heard a lot about that at Ochsner. We are leveraging technology to further ease this burden. I'm really looking forward to hearing how you do it. tell me.
Dr. Orabetz: So before we get into the details of pre-authorization, I want to level-set a little bit about the platform you're using for your EHR. We started exchanging data with major payers about three to four years ago and it exploded across the country.
Today, more than 200 organizations exchange data with 16 major payers, covering more than 100 million lives. So what we've seen is an explosion of data exchange between providers and payers. It actually started in the area of quality improvement and documentation excellence. However, we are now working with prior approval and the activity is progressing very quickly. And we're getting really good results, so let's talk about it in more detail.
Unger: So how does that tie in with the previous approval workload?
Dr. Orabetz: So the first thing we do is when we exchange data that is built into the pre-authentication process. The first thing to note is that pre-service and pre-authentication teams only log in to Epic. They do not visit paid websites. There are no additional logins. They use our EHR to communicate with payers.
Therefore, all requests currently processed or agreed upon early are submitted through the EHR platform and sent directly to the payer. And for the subset we defined in our early pilots, we're able to get approval right away about half of the time. Therefore, the process will be faster. If a problem arises, data can be exchanged between us and the payer.
The entire process significantly reduced authentication time and improved authentication efficiency. And when I talk to staff who do this every day, they find it incredibly transformative in their work.
Unger: I'd love to know if you have any stories for us or case studies or examples of how this experience might be different.
Dr. Orabetz: yes. As you know, the staff never leaves the EHR. So that in itself is a big plus. As I explained earlier, we as clinicians and other staff members do one thing every day. They log into our EHR. What we discovered is that we get answers faster when data is exchanged in real time. If an issue is identified, you can contact us. You can send clinical data directly to payers through your EHR. And what we found is that our case study shows a lot of automatic approvals.
Another thing that other organizations have demonstrated as well is that the amount of denials is decreasing rapidly. The number one reason for refusal that we are finding is lack of clinical documentation. And now you can serve it directly on the front end or send it as soon as you know you need it. So, I know I get asked this a lot. Doesn't sharing data lead to higher rejection rates? In fact, it's counterproductive. Sharing health record documentation reduces denial.
Unger: It's really amazing. I'm curious: Was it difficult negotiating with payers to change the system?
Dr. Orabetz: So I end up sitting at the table with the payers. You know, they're driving efficiency on the administrative side as well. So I think it's really a win-win situation for everyone. This is an advantage for providers as they can get faster answers and understand what documents need to be certified. Payers benefit because of increased efficiency.
But most importantly, it's a win for the patient, right? Care isn't delayed. Patients receive faster, more efficient, and more appropriate treatment in an evidence-based manner. So it's really a win all around. Therefore, everyone is actively involved, especially because they recognize the benefits for patients.
Unger: And speaking of win-win, this should have a dramatically positive effect on the physician and other members of the team. We know that our research core shows that prior authorization has a significant impact on physician burnout. Could you tell us a little more about the impact of the changes you're seeing in your own staff?
Dr. Orabetz: If you talk to our pre-service department, I think they are very happy with how our process is going. And we know that as this functionality is developed in the platform, it will become more and more efficient. In fact, I think a lot of it will be automated in a couple of years.
And we're very compliant with newly announced regulations, right? We know that by 2027, many pre-approval activities will need to be automated in electronic form. We are already on track to meet that requirement in 2024.
Unger: That's amazing. Are there any round numbers or rough numbers that can show the impact of this period?
Dr. Orabetz: You'll see a real improvement in the time it takes to get answers to your previous approval requests. Previously, this could take days or even weeks. Now it takes hours to days.
Unger: That's amazing. And we all know how important that time is. What did it take to set up the process in her own EHR?
Dr. Orabetz: So we're working with EHR vendors. And we've been through this. As you know, as I mentioned at the beginning, there are currently over 500 data connections between payer groups and provider groups across the country. So there's a pretty solid history at the moment of how to set this up, how to follow the rules of the road, how to exchange data. We can control what we share, and so can the payers. And we really came to understand that he was actually sharing what was HIPAA compliant in terms of treatment and licensing. So, things are going well so far. And I think we'll continue to bring even more benefits as the platform evolves.
Unger: I don't think there is a practice that wouldn't want to reduce the burden of pre-approval in some way. Are these types of changes you make exportable to other practices, or are they specific to your own system?
Dr. Orabetz: No, this is a standard platform that we are using. So this will continue to grow. As you know, over 200 organizations currently exchange data with payers. This will likely become the standard of care within the next 6 to 12 months. I guess everyone uses this. And we're adding even more features. Therefore, efficiency will only increase.
So you asked me earlier about what we actually saw? Literally, only hundreds of hours of staff time have been saved so far. It would be thousands. And when you multiply this by her 100 million lives on the platform, this is a very significant improvement in the current process.
Unger: oh. I don't know any doctor who wouldn't want to spend more time caring for a patient than prior authorization. That's really impressive. I'm curious as this is being developed, are there any other ways you are considering using this technology to reduce the burden of pre-authorization?
Dr. Orabetz: Yes, I think so. I think we'll see more and more automation over the next few years. And again, this will lead to new CMS requirements for data exchange expected in 2027. So I think we'll see more and more automation. We already do that within our EHRs. You know, I think AI is going to have a huge impact on this space as well in the next two to three years. As I said, we're in the very early stages of AI and really understanding what it's going to do and how it's going to improve our healthcare. It will also grow in this field.
Unger: Dr. Orabetz, thank you very much for joining us. This is a great example of how technology can be an asset to doctors, rather than a burden. Fixing pre-approvals is one of the AMA's top priorities. To support this effort, please become her AMA member at ama/assn.org/join.
That's it for today's episode. We'll have another AMA update of hers soon. Be sure to subscribe for new episodes and find all our videos and podcasts at ama/assn.org/podcasts. Thank you for joining us today. Please be careful.
Disclaimer: The views expressed in this video are those of the participants and do not necessarily reflect the views or policies of the AMA.
