Brenda Hopkins

The complex, highly manual prior authorization (PA) system continues to frustrate clinicians, negatively impact patients, and cost practices huge sums of money. The PA process causes frequent delays in care, often at the expense of patient health.

Technology is a significant part of the problem, despite years of efforts to streamline systems and speed up processes. A lack of coherent electronic systems has some practices resorting to paper faxing while others struggle to submit documents to multiple health plans’ proprietary web portals. As health plans add more drugs, procedures, and medical equipment to the long list of items requiring prior authorization, 

have been forced to hire staff dedicated entirely to submitting and tracking requests.

One of the first attempts at fixing the PA system was based on the HIPAA Healthcare Service Review X12-278 transaction standard. Unfortunately, the protocol wasn’t 

 enough to support all of the detailed clinical data necessary for PA.

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More recent streamlining efforts involve the Fast Healthcare Interoperability Resources (FHIR) standard, which is based on HL7 v2. FHIR combines the best features of HL7 v2, HL7 v3, and Clinical Document Architecture (CDA), while leveraging the latest web service technologies. The design of FHIR is based on RESTful web services–a contrast to the majority of IHE profiles which are based on SOAP web services. FHIR supports information exchange via mobile phone apps, cloud communications, EHR-based data sharing, and server communications. The Office of the National Coordinator for Health Information’s (ONC) 

calls for open APIs (application program interfaces) to be certified.

The industry seems to be coalescing around FHIR-based APIs, but how widespread the adoption will be is hard to predict. And although the major EHRs will likely adopt these standards quickly, smaller practices not using a certified EHR may have to wait months or years.

There are four best practices physician groups can implement as they wait for improved integration. All aim to lower PA-associated costs and shorten the time patients must wait for approvals.

 It’s not possible to have updated information on the PA-related policies for every health plan you work with. But it 

 possible to create clinician guides for the insurers you work with most frequently. If you limit the guide to the prescriptions, medical devices, and procedures your practice routinely recommends, the task is achievable. The guide should:

Inform clinicians about care recommendations that necessitate a PA

List the clinical documentation required by the health plan for approval of each care item.

Follow evidence-based guidelines to reduce denials

Standardizing on widely agreed upon clinical guidelines for all/most procedures and care recommendations speeds up the PA process and decreases denials. This is a three-pronged effort. First, decide if you’ll develop your own set of guidelines using a resource such as the National Guideline Clearinghouse or purchase them. Second, create a program to inform all clinicians about the guidelines to be used and the benefits of using them. Third, outline the steps needed when deviating from the standards (i.e., if the standard of care for knee surgery is X rehab days and your patient’s condition necessitates X+10 rehab days, what additional documentation will be required).

Discuss options for reducing PA volume with your main payers

Some payers are allowing PA exceptions for certain patients, such as those with multiple co-morbidities or who need a repeat procedure. Other payers are allowing physicians with proven patient-care track records or who are participating in risk-based payment contracts to bypass the PA process. Another option is bundled authorization for certain procedures, medications, or medical equipment for practices participating in alternative payment models.

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Practices waiting for EHR-based PA technology may want to consider a cloud fax solution. A 

 of physicians use phone or fax as the primary method of requesting PAs, so cloud faxing is a natural next step. More secure than traditional fax, cloud fax technology lets users quickly send email messages with attachments (e.g., clinical documentation) to other digital and physical faxes.

The pain caused by the current PA system is very real for both physicians and patients. The AMA’s Prior Authorization Physician Survey 

 that 44 percent said the PA process “sometimes” leads to care delays, and another 36% said it “often” does so. Almost 30 percent reported that the PA process has led to a serious adverse event for a patient.

A whopping 86 percent of physicians said they’d describe the burden associated with PA as “high or extremely high.” Slightly more than 35 percent said they have staff who work exclusively on PA, and the average number of PAs completed per physician per week in 2018 was 31.

For many physicians in small practices or rural areas, the discussions about HL7 and FHIR standards are nothing more than noise in their daily efforts to get patients the care they need in a timely manner. Indeed, the long battle between physicians and payers over the best way to get patients the care they need is raging hotter than ever, despite decades of effort to come together to create a solution.

Unfortunately for physicians, payers continue to demand prior authorization for more care items: 50 percent of physicians said their PA burden has increased significantly in the last five years.

The best practices described above are strong steps in easing that burden, allowing clinicians to spend less time on paperwork and more time with patients, as well as freeing up resources currently dedicated to the PA process to allow your business to grow.

is the Chief Health Information Officer for J2 Cloud Services. She specializes in the area of healthcare interoperability where she is focused on open data exchange of healthcare information inside and outside of the EHR and using open platforms and tools such as APIs as a means of sharing.

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Unfortunately for physicians, payers continue to demand prior authorization for more care items.

Grow your practice by optimizing your prior authorization process

The administrator for the Centers for Medicare & Medicaid Services has issued a challenge to make physicians’ offices fax-free by 2020. But old habits die hard, especially when it comes to physicians and their patients.

Despite the fact that 86% of physician practices have an electronic health record (EHR) system,

 many doctors still take notes by hand and utilize fax machines to send and receive data. Although advances have been made in technology, three-quarters of medical communication in the United States occurs by fax, which includes physical or legacy fax machines as well as more advanced faxing technologies such as cloud fax.

Digital cloud fax technology represents next-generation communication capabilities, as documents flow seamlessly through secure email or electronic health information exchange (HIE) and can become part of an electronic patient record.

The demise of the physical fax machine has been predicted for decades, yet it remains a healthcare workhorse. By breaking the habit of paper-based fax and adopting more modern communications channels such as digital cloud fax technology, physician practices can save money, adopt more efficient workflow practices and reduce the chances for a data breach.

Status quo tough to change                                                                                                              

The federal government offered more than $35 billion in incentives to encourage eligible professionals or eligible physician practices to adopt EHRs. While the adoption rate is high, the government didn’t mandate interoperability between systems, so disparate systems simply don’t talk to one another. Patient information such as a lab reports arrive via fax. Likewise, orders needing a physician signature, such as a care plan or a home health referral, remain mainly fax-based.

CMS Administrator Seema Verma addresses physical faxes and other forms of non-electronic communication when during a 2018 speech she says, “(H)ealth care providers are in a 1990’s time warp…where doctors are faxing patient records, medical staff are manually entering results into EHRs, and hospitals are handing out data on a CD-ROM while the rest of the economy is functioning on fully digitized, integrated data that informs decision-making instantaneously.”

The problem with all these technology systems is that interoperability among each remains poor. While strides are being made on that front, large gaps remain in a truly integrated patient record. Technology is one hurdle, but the possibility of competition cannot be overlooked.

EHR vendors don’t have much incentive to make their systems compatible with others for fear of losing market share. Health systems and providers, too, can be reluctant to transfer patient information electronically to another hospital or physician to slow patient leakage from their facilities, so they may not be keen to promote interoperability.

Despite the march of technological progress in the exam room, many physicians still rely on handwritten notes and refer to paper copies of records. The fax remains a reliable way to communicate, where records are returned in a familiar format. The comfort level with existing practices cannot be overlooked, nor can the lack of incentives and availability of improved options for document distribution to replace physical faxing.

The healthcare industry wastes more than $9 billion annually by continuing to use manual processes instead of electronic ones, according to the Council for Affordable Quality Healthcare. A manual process costs, on average, $6 more than an electronic one, but the difference can be as high as $11 more. Besides monetary savings, providers could save a minimum of 1.1 million labor hours per week by employing electronic transactions. Each fax or phone call requires an average of eight minutes to handle and as much as 30 minutes.

Multiply each manual process, each phone call, each sent or received fax, and the costs add up quickly.

Industry consolidation has brought a new level of interoperability that is breaking down some of these communication barriers.

But the biggest reason change needs to occur may be the lack of security for a paper fax. HIPAA regulations mandate a tight chain of custody at all times, but it’s difficult to imagine a tight chain of custody for a fax machine in the copy room. Multifunction scanners also can expose PHI.

With the cost of a healthcare data breach topping $8 million, health systems and providers must take all necessary precautions to ensure that patient data in all forms remains safe and secure.

Digital cloud faxing solves the problems and potential breaches associated with physical faxing. First, there is no more fax machine. Communications are sent by secure email, a fully HIPAA compliant solution. Documents are encrypted while in transmission and at rest, arriving directly in the in-box of the recipient, who logs in to view messages. Communications also can be sent through an HIE, another secure document exchange medium.

When deployed across an organization, faxes can be sent from any connected device: computer, tablet or smartphone through a secure mobile app. If communications need a higher level of security, documents can be stored in a secure server with 256-bit encryption.

If a breach occurs, companies that use HIPAA-compliant cloud faxing would be covered by the “safe harbor” provision of the Breach Notification Rule because the encrypted data had been rendered unusable, unreadable, or indecipherable to unauthorized individuals. “If protected health information is encrypted pursuant to this guidance, then no breach notification is required following an impermissible use or disclosure of the information.”

The days of the physical fax machine are numbered – and physician practices would be smart to cut those ties sooner rather than later. Digital cloud faxing combines the utility of faxing with the security protocols that HIPAA regulations and commonsense demand while presenting information in a way that physicians and staff are accustomed to.

Brenda Hopkins, eFax Corporate Chief Health Information Officer, specializes in the area of healthcare interoperability where she is focused on open data exchange of healthcare information inside and outside of the EHR and using open platforms and tools such as APIs as a means of sharing. She started her career as a pediatric/neonatal transport nurse and brings a patient/user centered team-oriented approach to technology build and enablement for leading software solutions.

Prior to joining eFax Corporate, Hopkins held leadership positions at GE Healthcare, Kaiser Permanente and Adventist Health purchasing, building, implementing and scaling large enterprise EHRs and ancillary solutions with a strong focus on meeting clinical, revenue, safety and quality goals in value-based payment models and care delivery programs.

 The Centers for Disease Control and Prevention. Electronic Medical Records/Electronic Health Records (EMRs/EHRs). https://www.cdc.gov/nchs/fastats/electronic-medical-records.htm. Accessed August 27, 2019.

 Vox. The fax of life: Why American medicine still runs on fax machines. https://www.vox.com/health-care/2017/10/30/16228054/american-medical-system-fax-machines-why. Accessed August 27, 2019.

 CMS.gov. SPEECH: Remarks by Administrator Seema Verma at the ONC Interoperability Forum in Washington, DC. https://www.cms.gov/newsroom/press-releases/speech-remarks-administrator-seema-verma-onc-interoperability-forum-washington-dc. Accessed August 23, 2019.

 CAQH. Reducing Manual Business Transactions Could Save Healthcare $9.4 Billion. https://www.caqh.org/about/press-release/reducing-manual-business-transactions-could-save-healthcare-94-billion. Accessed August 27, 2019.

Why the old-fashioned fax machine needs to go.