Why Outsource Prior Authorization?

04/12/2016

Today, a lot of health plans are asking themselves these questions: “Why outsource prior authorization to a specialty vendor when the health plan is the one controlling the daily tasks of the operation? Wouldn’t this just add more complication to the process?”

While it may appear that way at first glance, many health plans discover that the result is quite the opposite.

Although health plans can establish and run their own prior authorization (PA) programs in-house, many find that it is simply not cost effective to do so. In fact, prior authorization is very expensive and complicated to do internally. “To run a successful program, the health plan has to write clinical guidelines and it is a tremendous expense to keep these up to date – not to mention very time-consuming,” said Dr. Robert Neaderthal, an internist with more than 20 years of practice, and current medical director at eviCore healthcare (eviCore).

In addition, health plans need a large team of physicians, representing a wide array of specialty clinical expertise, to properly review each prior authorization request, and make and support appropriate determinations. Dr. Robert Westergan, Chief of Musculoskeletal Programs at eviCore, referred back to his days as a practicing orthopedic surgeon when he said, “The biggest frustration I found when working with a health plan that had a small in-house prior authorization program was the lack of same-specialty clinical expertise. For example, a surgeon might put in a request for a spine surgery, and a pediatrician would be the one reviewing the PA request. It just didn’t make sense and seemed really unfair to the patient.” He continued, “At eviCore, we have the luxury to offer same-specialty peer-to-peer reviews in complex PA requests for most clinical specialties. “

Furthermore, building out the technology and operational infrastructure of a successful prior authorization program is no easy – or inexpensive – task. For increasingly busy providers, it is crucial to offer a system that is convenient and easy-to-use, e.g., accessed via an online portal, where requesting a PA is quick and the response is detailed, accurate, and fast. Such a system has already been built within eviCore and streamlined across our solutions.

At eviCore, we have over 21 years of experience in running successful prior authorization programs for more than 100 health plans across the nation. We formulate our evidence-based guidelines in consultation with the leading specialty and primary care organizations in the United States and annually – or sooner, when appropriate – update these guidelines on our website. Additionally, we have over 200 medical directors and 700 nurses on staff, covering 28 different medical specialties. Armed with this specialty expertise, thought leadership, and advanced technology, eviCore continues to partner with health plans and risk-bearing providers across the nation to enable better outcomes for patients.