GAO Findings on Prior Authorization and HATA’s Survey

HATA survey reveals membership dissatisfaction with prior authorization transactions.

In a recent report to the U.S. Senate Committee on Finance, the Government Accountability Office (GAO) was asked to examine the Centers for Medicare & Medicaid Services’ (CMS’s) prior authorization programs, including its benefits and challenges. The GAO spoke with many providers, suppliers, and beneficiary group officials who reported on the benefits of prior authorization. However, these same groups also reported challenges, including difficulty obtaining the necessary documentation from referring physicians to submit a prior authorization (PA) request, even though CMS had created templates and other tools to address this concern.

In a study presented to the Healthcare Administrative Technology Association (HATA), the association representing the practice management system (PMS) industry, the American Medical Association (AMA) found why providers were so dissatisfied with the prior authorization transaction. The AMA reported that prior authorization requirements among different payers are inconsistent. Many providers are rarely aware of what information is required for a prior authorization, which leads to a significant amount of back-and-forth between the provider and the payers, resulting in more care delays and frustration on the provider’s behalf. It also found that multiple routes exist to obtain PA, depending on the health plan, drug, pharmacy, and patient combination.

The Workgroup for Electronic Data Interchange (WEDI) Prior Authorization Workgroup identified what may be behind such a current lack of integration: the deficiency of interoperability between a provider’s administrative (practice management) and clinical (electronic health record) systems. This lack of integration makes it challenging for providers to electronically pull together and send health plans all the information needed to support prior authorizations. 

In 2017, HATA conducted a survey of its PMS vendor members and found that only 33 percent offer the prior authorization transaction (278) to their providers. Of those clients utilizing the 278, all of them are using it for referrals only, not prior authorization. Reasons the PMS vendors do not offer 278 include the following:

• Lack of provider interest (63 percent)
• Lack of payer commitment (63 percent)
• Development limitations (50 percent)
• Unreliable information exchange (25 percent)
• Interoperability challenges (12.5 percent)

The comment heard over and over was that there was a general industry lack of understanding due to non-use and lack of implementation. One hundred percent of respondents answered that only 1-10 percent of clients currently utilize the 278 transaction. The survey can be found on the HATA website at  http://www.hata-assn.org/general-resource-page.

Regarding the lack of administrative and clinical integration, the HATA workgroup noted that the electronic health record (EHR) flows to the practice management system, but the practice management system doesn’t flow to the EHR. Therefore, if the 278 is initiated on the clinical side, the assigned PA number must flow back into the PM system to be placed on the claim for appropriate adjudication by the insurance company.

HATA is about to launch an incubator project that will bring together the practice, the practice management system vendor, the electronic medical record vendor, the clearinghouse vendor, and the payer (which may or may not include a third-party administrator) to walk through this process from beginning to end. By using real data, HATA will have all the elements in place to make significant improvements to the process.

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