Electronic Prior Authorization in Massachusetts

June 1, 2023 David Delano


Electronic prior authorization (ePA) in Massachusetts is positioned well and ready for the next steps in a coordinated, collaborative statewide implementation push. MHDC, the Network for Excellence in Healthcare Innovation (NEHI), and The Automation Advisory Group (TAAG) composed of experts in healthcare policy, operations, and clinical care spent a lot of time teasing apart the benefits, challenges, and opportunities a fully automated ePA workflow would bring. We concluded that an automated workflow process is an essential component of reforming prior authorization. It creates the opportunity for great burden reduction on both payers and providers while also providing a platform on which other reforms could be considered and built.

Data collection is an essential piece of the ePA workflow. Having better data collection of the number of authorizations requested, approved, pended, and denied as well as the clinical scenarios and scope they cover is necessary to support adjustments to the process moving forward. Prior authorizations are not going away and in some cases are being expanded despite public announcements that the number of PAs will be cut moving forward (for example, just weeks after announcing a 15-20% cut in their PA requirements nationally, United Healthcare announced they will now require prior authorization for all colonoscopies performed nationally).

We believe PAs can be clinically and financially beneficial for patients, members, payers, and providers when used appropriately.  Delivering high value, clinically appropriate, and timely care is the goal. Prior authorizations can help support this if used well and automation can help reduce both the burden of PAs and the time delays they sometimes bring to necessary care.

Automation is complex and requires all parties to participate in order to work. In our presentations to the Health Policy Commission (HPC), MHDC recommended a state mandate requiring all payers and providers adopt ePA over the next 2.5 years (by Jan 1, 2026, in line with the deadlines in the proposed federal rule that requires Medicare Advantage, Medicaid, CHIP, qualified health plans on the exchanges, and other public plans to establish an ePA API by that same date). The API in the related CMS proposed rule is called PARDD (Prior Authorization Requirements, Documentation and Decision) and recommends but does not require the use of the three DaVinci prior authorization implementation guides (the CRD, DTR, and PAS IGs) to meet the API requirements - you can find the full proposed rule HERE. In Massachusetts we intend to go one step further and explicitly require the use of these three IGs for all payers and providers in the state.

The guides are maintained by an HL7 (Health Level 7) FHIR (Fast Healthcare Interoperability Resources) accelerator group called DaVinci. The IGs are continually evolving and still under development but it is our belief that we can require compliance with the IGs and as they change and new requirements or features of the IGs become available Massachusetts can adopt them as they are released in a coordinated manner.

We recommend some small, complementary additions to the workflows outlined in these IGs. For example, we recommended adding trackable codes that act as confirmation of the CRD response. If a provider is told no PA is needed, they will be able to supply this code later as proof of the response if someone tries to indicate otherwise. If this happened and the provider could supply the confirmation code showing they were told no PA was needed, the payer would be required to honor the original response.

We have also recommended establishing a centralized, coordinated implementation assistance function where payers and providers can seek trading partner relationships, seek technical assistance, and communicate to other participants about the process. This office would be called the Technical Assistance Center or TAC and would operate like a program management office with resources and tools available to assist payers and providers statewide with both technical and process issues related to ePA implementation.

There would be a statewide workplan for the participants, access to technical solutions and resources, status meetings on progress, and overall project support included with TAC. We recommend a shared service model using a consistent set of tools and standard capabilities in a secure subscription environment that payers can choose to use for several functions including the PARDD/Da Vinci APIs described above. Initially it would support coverage requirements and discovery (CRD) then expand to include the rest of ePA and beyond.

We believe that starting with the simple clinical use cases and advancing both capabilities and complexity over time is the right approach. This will be an entirely new workflow and set of tools for payers and providers to integrate into their systems, processes, and workflows. We see the TAC as the arbiter of decisions about what to tackle next and where to focus time and resources collectively for the most benefit across the largest number of participation using insight provided by both users and the task force outlined below.

We have also recommended the formation of a centralized, cross discipline ePA Task Force whose role would be to collect and collate data from the participating organizations across the state and to work with policy makers regarding other (non-automation) reforms to PA processes. We are aware of proposed state legislation from Senator Friedman (D – Fourth Middlesex) and other proposed legislation. These legislative efforts could significantly alter the current prior authorization landscape in Massachusetts without taking into consideration the benefits and mechanisms that an automation strategy offers. At the same time they could help pave a way to reforms and improvements in a coordinated and thoughtful way. The Task Force would be charged with reviewing data and making recommendations as appropriate to ensure the role of ePA is part of the overall policy considerations.

The MHDC, NEHEN, and NEHI team met with the Commissioners of the Health Policy Commission on May 10th to present all of the above findings, feedback, survey results, and recommendations of the TAAG workgroup. The feedback was generally positive with good engagement by the commissioners and an excellent Q&A session ensued where it was clear this is an important and worthwhile topic.  We expect more feedback from the from the HPC at their next board meeting as well as ongoing guidance and PA-related action from the HPC.

We expect easier access to prior authorization and faster processing to increase the number of related transactions greatly. It’s easy to imagine every clinical order written daily in an EHR being validated against a set of CRD rules for coverage, not to mention any additional ad-hoc inquires about prospective care. The infrastructure and services to support this volume of transactions is foundational, and will expand adoption of additional transactions in other areas using the same infrastructure, but it will cost real money to successfully implement. Financial support is crucial to overcome budget constraints for payers and providers engaging in the ePA process. Massachusetts should explore state and federal funding opportunities to facilitate compliance and foster successful automation implementation.

Throughout this statewide process we have remained engaged with the federal rulemaking process and are confident that we are positioning ourselves well to be well prepared for the upcoming final CMS rule covering prior authorization. Once the CMS rule is finalized we expect to see related certification requirements from the Office of the National Coordinator of Health IT (ONC), most likely as part of an upcoming proposed interoperability rule currently dated November 2023. Even knowing that this is coming and feeling relatively well prepared, there is not a lot of time before the January 2023 deadline. Fasten your seat belts – enjoy the ride!

Want to read the joint NEHI-MHDC report covering ePA in Massachusetts? Find it HERE.

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