For the previous a number of weeks, Healthcare Innovation has been placing a highlight on the progress that well being plans and suppliers are making to adjust to the CMS Interoperability and Prior Authorization Ultimate Rule as a way to increase transparency and effectivity. We’re additionally among the methods AI is impacting the prior auth interactions. In an e-mail Q&A, Tracy Alvarez, vice chairman of Medical Care Options for Blue Defend of California, described the group’s effort to cut back supplier and member abrasion round prior authorization. The nonprofit group has 6 million members, over 6,500 staff and greater than $27 billion in annual income.
Healthcare Innovation: In a latest WEDI survey concerning the challenges of assembly CMS interoperability necessities round using FHIR utility programming interfaces (APIs) for prior authorization, well being plans respondents mentioned their prime issues are digitizing insurance policies, assembly compliance timelines, and delegated third events going through challenges with completely different techniques. Would Blue Defend say these issues talked about within the WEDI survey align with the problems it sees as prime of thoughts? As an illustration, do you may have an answer for digitizing all of your insurance policies for prior auth? Or are there different points you might be working via?
Alvarez: Plans that haven’t begun planning or implementing the digitization of insurance policies could certainly be pressed to conform by 1/1/27. At Blue Defend of California, our objective is to cut back supplier and member abrasion round prior authorization. This isn’t a easy activity, and we’ve had a number of pivots in our method alongside the best way.
We’ve been designing our mature and scalable resolution to digitize all medical insurance policies, together with prior authorization insurance policies, for a number of months. Our centralized medical coverage repository will seize all insurance policies in a machine-readable format versus PDFs so we now have a single supply of fact that may be constantly interpreted throughout platforms. Digitization can even enhance automation for these therapies that want assessment, leading to quicker solutions for members and suppliers.
One other alternative is to make interoperability options extra helpful for suppliers. We’re prioritizing knowledge engineering work behind the scenes that can let suppliers know precisely when an authorization is required and in addition information and assist them via their prior authorization requests.
HCI: Blue Defend introduced it was going to work with Salesforce on a previous authorization resolution. Are you able to describe the progress to this point on standardizing this digital prior auth platform? What points need to be labored via earlier than its launch?
Alvarez: We’ve got accomplished improvement work with Salesforce, which can function our prior authorization interoperability hub to attach suppliers, payers, and specialty healthcare providers. We’re additionally about to launch our digital entrance door to a choose group of suppliers, which can assist them in submitting prior authorizations inside their present workflows. We need to meet suppliers the place they’re, so we’re taking what we be taught with this group and making use of it as we scale to extra suppliers.
HCI: Is there a job for AI in automating among the course of?
Alvarez: There’s a function for synthetic intelligence to automate some guide prior authorization processes to hurry time to care. Blue Defend’s resolution intends to assist human medical evaluations by creating determination timber that mechanically authorize care when all the required knowledge is current. Blue Defend is simply enabling synthetic intelligence-powered capabilities to approve care, route prior authorization requests for clinician assessment, and current all the related medical info to a doctor or licensed medical skilled to make an evidence-based care willpower. We are going to by no means let synthetic intelligence expertise deny care. It’s California regulation that synthetic intelligence expertise can’t be used to mechanically deny, delay, or modify care, and we additionally imagine it’s the fitting factor to do.
HCI: Does Blue Defend have a challenge staff and/or a supplier associate that it’s working with on the FHIR API improvement and testing?
Alvarez: Blue Defend started our journey in mid-2024 to create a complete prior authorization platform resolution as a result of we acknowledged the significance of making certain our members obtain evidence-based care in a well timed method. We created a devoted staff of quite a few leaders, technical leads, expertise companions, and different medical stakeholder teams who’ve been diligently creating Prior Authorization Reimagined for our suppliers and members with FHIR APIs. We’ve got additionally partnered carefully with a serious supplier in California all through our portal improvement and testing phases to make sure what we’re constructing works seamlessly throughout the supplier workflow. At this level in our improvement, we’re assured that we are going to be compliant with the CMS mandate for 1/1/27.
HCI: On the supplier aspect, do the EHR distributors need to make modifications to their techniques for the prior auth APIs on the payer aspect to be put to good use?
Alvarez: EHR distributors are able to significantly enhance the supplier expertise by enabling authorization requests to entry and leverage medical notes throughout the suppliers’ workflow. Such enhancements would guarantee Blue Defend and different payers obtain the info we have to make a previous authorization willpower, whereas minimizing administrative burden for the supplier to allow them to give attention to affected person care. Recognizing some suppliers’ EHRs could not have this performance, Blue Defend additionally accepts prior authorizations via supplier portals and different channels as a way to meet suppliers the place they’re.
HCI: Anything you wish to say about your expectations for the way these tech and coverage options will easy the prior auth processes?
Alvarez: We imagine that to easy prior authorization processes, payers have to prioritize extra than simply compliance actions. The way forward for prior authorization is accuracy, effectivity, and approval of evidence-based care on the primary strive.
In creating Prior Authorization Reimagined, we discovered that eradicating present guide processes from prior authorizations requires a extremely advanced resolution. As is the case when creating new options, every iteration of supply and testing gives alternatives and concepts for find out how to operationalize a brand new system for prior authorizations, so members constantly obtain care in a well timed method.
As soon as we now have our basis, we are able to then give attention to delivering a extra customized, high-tech and high-touch prior authorization expertise for our members that features numerous communication applied sciences and join members to further well being care and providers.
HCI: Are there ways in which better interoperability between payers and suppliers can be utilized for different use instances round member identification, engagement and fee? Or for value-based care applications?
Alvarez: Sooner or later, better knowledge sharing between payers and suppliers may enhance identification and determination of suspected care gaps, transparency of reimbursement insurance policies and out-of-pocket prices for members and in the end function a foundational functionality for the longer term imaginative and prescient of real-time claims achievement.
HCI: In 2025, Blue Defend made some commitments round prior authorization. May you present any updates or better element about any of the next? The primary is standardizing supplier submissions for digital prior authorization, giving medical doctors extra time for sufferers by lessening administrative burden.
Alvarez: Blue Defend of California is dedicated to streamlining prior authorization workflows to make sure a extra environment friendly and clear course of, whereas sustaining vital evidence-based care requirements for members. We introduced our intentions in October 2024. In 2025, we signed on to the AHIP commitments with different Blue Cross Blue Defend Affiliation plans. We imagine realizing these commitments will lead to considerably improved prior authorization experiences for our members.
HCI: The second is additional lowering using prior authorization for sure in-network medical providers by 2026.
Alvarez: Whereas we actually intention to cut back the amount of prior authorizations, we actually see a better alternative to extend the automation of guide prior authorization processes and make extra prior authorization determinations in actual time, which can guarantee our members have entry to well timed, evidence-based care once they want it.
This 12 months, Blue Defend of California can even proceed to advance what we now have already accomplished to cut back necessities for prior authorizations for members with established, ongoing wants associated to power situations.
HCI: The third is making certain a seamless course of for members who swap medical insurance corporations by honoring their earlier medical insurance firm’s prior authorization approvals for benefit-equivalent in-network providers as a part of a 90-day transition interval, by 2026.
Alvarez: Blue Defend of California’s Continuity and Coordination of Care Program is designed, partially, to advertise steady and applicable care and supply well timed assessment and authorization for members needing ongoing therapy, when care disruptions could in any other case happen.
Our program ensures that members with advanced, power, or acute wants, in addition to these requiring maternity, pediatric, or specialised tools/providers, expertise seamless transitions and uninterrupted care throughout supplier or plan modifications, and totally adheres to all state and federal necessities for continuity of care.
HCI: One other objective is making the method extra clear by making certain communications to members about prior authorization are clear and include customized info, together with what is required to assist approval, subsequent steps and obtainable attraction processes.
Alvarez: Transparency in communications to members about prior authorization is a cornerstone of Blue Defend’s method. We intention to empower members to extra effectively navigate subsequent steps in care by offering clear, individualized, and consumer-friendly notices about prior authorization choices. By making the explanations for any non-approval clear and actionable, our method is designed to speed up medical follow-up. We additionally commonly replace medical pointers and prior authorization lists on supplier portals and public web sites, so our members, suppliers, and companions are conscious of present prior authorization necessities.
HCI: One other is fast-tracking responses for digital prior authorization requests by committing to answering at the very least 80% of requests in close to real-time in 2027.
Alvarez: Blue Defend’s Prior Authorization Reimagined initiative goals to streamline the prior authorization course of for suppliers and members. This 80% metric is essential to lowering abrasion within the system and requires the profitable completion of many actions. We at present have the inspiration in place that checks if an authorization is required by parsing in real-time: prior authorizations on the requested therapy, member eligibility, enterprise guidelines, and digital consumption automation. To get us to the 80% auto approval charge, we’re working with trade companions to develop and deploy further determination tree (DTR) capabilities. We’ve got already coded a big variety of medical insurance policies as a part of this effort.
HCI: The ultimate one is affirming that licensed physicians personally lead evaluations of unapproved prior authorization requests.
Alvarez: Blue Defend solely has certified licensed professionals (QLPs) assessment supplier requests for well being care providers. Moreover, QLPs consider these medical points that align with their medical space of experience. When mandatory, specialty peer assessment evaluations could also be requested and returned to the Medical Director for assessment and last willpower.
