CAQH CORE Urges Industry Collaboration on Prior Authorizations

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By Thomas Beaton

– CAQH CORE is urging healthcare payers, providers, and other stakeholders to promote industry-wide collaboration on how to improve prior authorizations.

Leading provider and payer organizations, including AHIP, AHA, the BlueCross BlueShield Association, and MGMA, have already signed an agreement to reduce complexity and standardize the processes of prior authorization.

“We are greatly appreciative of the consensus statement authors’ commitment to this critical issue,” said Robin J. Thomashauer, President of CAQH. “CAQH CORE participating organizations have spent considerable time developing ways to promote greater automation in the prior authorization process. We agree wholeheartedly with the consensus statement, and are eager to work together to make a difference.”

CAQH CORE and the signatories of the consensus letter aim to improve prior authorizations with two-way communications and transparency, so all stakeholders can easily process prior authorization requests.

In addition, both CAQH CORE and the signatories want to add features to prior authorizations that address continuity of care concerns and leverage electronic prior authorizations to enhance efficiency.

Prior authorizations help payers contain care costs for expensive medications and services, but can also contribute to delays in care and add patient safety risks. Payers that utilize electronic and streamlined prior authorization processes could help reduce patient delays in care and experience significant savings.

CAQH CORE believes that standardizing prior authorization could help cut back on high administrative spending rates.

“According to the 2017 CAQH Index, adoption of the standard prior authorization transaction by health plans and healthcare providers could result in savings of $6.84 per transaction, one of the most significant per transaction opportunity areas,” CAQH said.

“However, the proportion of prior authorization transactions using that standard actually declined by more than 10 percentage points from the 2016 Index report.”

CAQH urged the provider and payer organizations to become CORE-certified and adhere to industry standards for prior authorization. CAQH believes that their organizational focus on healthcare administration will foster industry collaboration to make positive changes to prior authorization requests.

“Cross-industry collaboration is essential to improve prior authorization, and we stand ready to support your efforts,” CAQH said.

“Endorsing the CAQH CORE Operating Rules and encouraging your members to become certified will be a meaningful and immediate step forward for your initiative. Following these rules should reduce unnecessary manual interventions and, ultimately, improve the timely delivery of patient care.”