Dive Brief:

  • Epic announced Monday the launch of a tool that enables clinicians to instantaneously determine whether an insurer requires prior authorization for medical treatments, according to the electronic health record vendor's announcement.
  • Four health systems — Ochsner Health, Froedtert ThedaCare Health, Denver Health, and Summit Health — are the first adopters of the technology, which is embedded within Epic's electronic health record.
  • These health systems will be able to see whether prior authorization is required by insurers UnitedHealthcare, CVS' Aetna, and Network Health. Epic stated that sixteen additional payers are currently testing the interface.

Dive Insight:

Prior authorization — the process requiring patients and their doctors to request coverage for a medical item or service before it is provided — has long been a source of frustration for clinicians, who argue it blocks timely care and burdens them with excessive paperwork.

Despite efforts to digitize prior authorization, the process remains largely manual, forcing clinicians to contact insurers by phone or fax, navigate multiple insurance portals, and keep up with evolving requirements.

Epic aims to alleviate these issues with a new application programming interface (API) called Coverage Requirements Discovery.

APIs are sets of rules that enable computer programs to communicate directly with one another. This particular API, developed by international data standards organization Health Level Seven International using the Fast Healthcare Interoperability Resources (FHIR) standard — a widely recognized framework for health data exchange — allows providers to check immediately whether a medical service requires prior authorization. According to Epic and the participating systems, it eliminates the need for clinicians to manually track down specific insurer requirements.

“This will reduce administrative burden, improve efficiency, and minimize delays in patient care,” said Melissa Woods, Ochsner Health's assistant vice president of revenue cycle and financial clearance, in a statement.

The launch also helps providers meet the requirements of a federal interoperability rule that mandates most Medicaid, Medicare Advantage, and Affordable Care Act marketplace insurers to implement prior authorization APIs by Jan. 1, as noted by Epic. These APIs must include a list of covered items and services, guidance for documentation requirements, and support for completing requests and responses.

The sweeping final rule also requires insurers to expedite prior authorization decisions, provide specific reasons for denials, and publicly report certain prior authorization metrics. Those provisions took effect at the start of this year.

This rule is one of several regulatory efforts to improve the often-criticized prior authorization process. In May, the agency secured a pledge from companies participating in the Health Tech Ecosystem — an initiative to increase access to digital health tools and improve health data sharing — to address challenges in prior authorization.

Insurers also report taking steps to streamline their preapproval requirements. Last summer, the Trump administration secured voluntary pledges from insurers to reform prior authorizations, and as of this spring, the companies say they have cut 11% of the policies.