New partnership offers near real-time prior authorization answers

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Blue Shield of California, the nonprofit health plan, has announced a partnership with Salesforce, the cloud-based customer relationship management (CRM) software, intent on cutting down the time spent waiting for prior authorization answers for physicians and their patients. The partners’ platform solution will be built on Salesforce Health Cloud, connecting members to personalized health support by automatically alerting care teams about prior authorization requests.

Using Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) standards, Blue Shield plans to build technology capable of streamlining over 20 disparate systems into just one process that will integrate into physicians’ daily workflow. The platform will search a patient’s EHR for relevant clinical information, compiling it into a pre-populated electronic form. Physicians will be able to submit requests from their systems in real-time, and patients will receive answers during their appointments.

When cases require clinical consultation, physicians will be notified with details of what is required for authorization, with options to begin a peer-to-peer clinical consultation. Blue Shield’s plan is to expedite this process from several days to just hours, depending on the requesting physician’s availability.

“Prior authorization was never meant to be a barrier or a burden. As a health plan, it’s our responsibility to ensure safe, evidence-based, high-value care for our members, and we know it can be an easier process for everyone,” Paul Markovich, CEO, Blue Shield of California, said in an organizational release. “That’s why we are taking the bold step to make it as easy as using your credit card, while enabling more coordinated, personalized support for members. It is time for the industry to let go of fax machines.”

According to the American Medical Association’s annual survey, 78% of physicians reported that issues with prior authorizations can lead to patients forgoing care. The news release attributes this, in large part, to outdated and inefficient healthcare industry processes. Currently, about 2/3 of prior authorization requests are submitted manually, or partially manually, including by fax machine. The prior authorization process is often made slower by submissions that lack complete clinical information. Both time and resources are wasted by outdated electronic systems while patients are left without answers.

“For years, we’ve heard that technology will be the answer to systemic issues in health care, but few solutions have made a scalable impact,” Jeff Amann, EVP and GM of Salesforce Industries, said. “With Blue Shield of California, we’re rebuilding the prior authorization process with new innovations that support near real-time decision-making so providers can more quickly, transparently and compliantly deliver the attentive care their patients deserve.”

The platform will work alongside Care Connect, Blue Shield’s care management system, to create clinical infrastructure that emphasizes ongoing, preventative care and wellness. The goal is for future prior authorization requests to directly alert the health plan’s team of nurses, social workers and behavioral health specialists, informing them that a member may need new levels of support.

“As a practicing physician, I’m proud that we’re taking on this challenge to build a solution that allows providers to focus on delivering care – why they became physicians in the first place – rather than adding to the administrative burden,” Ravi Kavasery, M.D., CMO, Blue Shield of California, said.