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REPORT: MASSACHUSETTS SHOULD MANDATE PRIOR AUTHORIZATION AUTOMATION

April 26, 2023
Network for Excellence in Health Innovation says that Massachusetts should
pursue automation both to achieve compliance with upcoming federal rules and to
alleviate the burdens and costs of current prior authorization processes
David Raths
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Photo 144145971 © Tyler Oneill | Dreamstime.com



The Network for Excellence in Health Innovation (NEHI) and the Massachusetts
Health Data Consortium (MHDC) have issued a report recommending that
Massachusetts should take a leadership role in promoting the automation of prior
authorization (PA) by creating structures and incentives that coordinate payer,
provider, and vendor activities.

NEHI is a national nonprofit, nonpartisan organization composed of stakeholders
from across key sectors of health and healthcare. Its Prior Authorization
project work was supported with funding from the Massachusetts Health Policy
Commission, Change Healthcare, Cohere Health, Hook, and ZeOmega.

The Centers for Medicare & Medicaid Services (CMS) has put out a Proposed Rule
on Improving Prior Authorization. The report suggests that Massachusetts should
pursue automation both to achieve compliance with the new federal rules and to
alleviate the burdens and costs of current PA processes. The NEHI
recommendations include guidelines for drawing an automation roadmap and the
structures needed to support the coordination and expertise needed for statewide
implementation. Its recommendations are designed to advance the adoption of
automated PA among Massachusetts payers and providers by 2026.



Project leaders have been working with participants from across the healthcare
system, which came to be known as The Automation Advisory Group (TAAG).
Consisting of payers, providers, technology companies, EHR vendors, and state
and federal representatives, TAAG provided feedback on existing guidelines for
automation (the Da Vinci Implementation Guides [IGs]), informed by their
experiences and capabilities.

The report states that the Commonwealth should use state regulatory authority to
mandate automation based on a technical roadmap. “While there is much that can
be accomplished without a state mandate, TAAG participants favored the adoption
of a coherent requirement to proceed with automation.”

They noted that automation cannot achieve its intended benefits without the
participation of different sectors of the healthcare community. “Providers and
payers must both make changes in their workflows and systems to achieve expected
benefits. Detailing what each sector must do to proceed with automation removes
the friction that would inevitably occur among stakeholders, including vendors.
In addition, a state mandate will improve the efficiency with which automation
is adopted as payers, providers, and vendors travel down the same path and can
take advantage of lessons learned. Finally, a state mandate will standardize the
process so that providers and payers will have the same ground rules and
expectations when interacting with each other, despite variation in PA
requirements among payers and variations in EMRs among providers.”

The authors believe that from a political standpoint, a mandate in this area is
unlikely to garner strong objections. “Promulgation of the CMS Proposed Rule
strongly signals that the industry must move in this direction. A mandate
consistent with the Proposed Rule as finalized simply organizes and promotes
forward movement in a manner consistent with the Commonwealth’s circumstances
and goals. Moreover, both stakeholders and state agencies have highlighted the
need to remove waste and burden from the system considering the Commonwealth’s
coverage and cost control objectives.”




In addition, through its authority to regulate hospitals and oversee physicians’
practice of medicine, the authors recommend that the state mandate adoption of
those activities that will enable automation of PA requests.

When they discussed oversight of the mandate with TAAG, the authors recommended
that 
the Health Policy Commission (HPC), which is charged with “monitoring
health care spending growth in Massachusetts and providing data-driven policy
recommendations regarding health care delivery and payment system reform,” could
be an appropriate Agency within which to locate this responsibility. The
Division of Insurance (DOI) or 
the Executive Office of Health and Human
Services (EOHHS) might also be considered.

Legislation will be needed to address some of the responsibilities envisioned,
the report says. “The state will, for example, need to obtain data from both
providers and payers. In addition to monitoring progress in implementing the
technical stages of automation, the recommendations include that the responsible
Agency develop measures that connect to three goals as part of the automation
mandate: 1) improving trust in the process by increasing
the transparency of PA
functions; 2) providing information that enables an evidence base for continuing
PA reforms; and 3) measuring administrative savings achieved. Data reported
should be made transparent to payers, providers, and consumers in an accessible
manner.”

Automation will yield standardized data elements that are useful for all
stakeholders involved in the process. At a minimum, devising mandated reporting
on simple metrics such as services subject to PA, PA response times, and payer
rates of denials will be critical to showcase process transparency, the report
says. Measures that clarify the frequency with which providers request different
services subject to PA and automation adoption rates will also be important.



To ensure that all providers and payers are able to adopt the required
technological and process changes that automation requires, the state should
make available need-based financial assistance, especially for MassHealth and
organizations that serve MassHealth members, the authors suggest. By supporting
centralized technical assistance, however, the state may efficiently reduce the
support required.




 




 




 




 










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