According to CAQH, the biggest challenges to DME prior authorization automation include data inconsistency, restricted vendor options, and lack of compatibility. According to the 2018 CAQH Index, just 12% of the 182 million medical sector DME prior authorization transactions were electronic in 2018. This suggests, despite other federally mandated HIPAA electronic transactions, DME prior authorizations transactions are still pretty much mechanical. According to a recent American Medical Association survey, physicians are still predominantly using
- Phones
- Faxes
- Emails
To conduct the DME prior authorization process, leading to increased administrative overhead, care delays, and even serious adverse events. Both payers and providers agree that the key to lowering the burden of DME prior authorizations is automation.
So, why is the DME prior authorization process still mostly done by hand?
CAQH highlights the key difficulties preventing the industry from automating the DME prior authorization process from start to finish in a new white paper.
- The necessity for data consistency
- A lack of attachment standards
- Poor integration between clinical and administration systems
- A lack of vendor products
- State requirements for manual intervention
- A lack of provider understanding
is among the problems
The Industry Requires Consistent Data
Payers are inconsistent in their use of codes to communicate prior authorization status, errors, and next actions, including the requirement for clinical documentation to verify medical necessity, according to CAQH, which is a key impediment to end-to-end automation. In a setting where permission criteria vary between health plans, providers lack an effective means to identify what relevant information to provide in the request.
There is a lack of code homogeneity, and the use of overly generic codes that do not provide clear direction and next steps. Further impede provider adoption of the standard transaction, the council notes in the white paper. When it relates to DME prior authorizations, major sector stakeholders have been advocating for greater openness and public administration.
Attachments and Clinical Documentation Have No Mandated Standards
Clinical documents and other attachments that illustrate a patient’s clinical situation assist health plans in determining medical necessity and appropriateness. However, the lack of an attachment standard or uniformity between plans frustrates not only providers, but also the industry as a whole, according to CAQH.
When healthcare plans want varying levels of clinical documentation information on DME prior authorization requests, vendors find it challenging to design systems that fulfill HIPAA’s electronic standard for prior authorizations, according to the council.
Inadequate Integration of Clinical And Administrative Systems
Interoperability has been a key issue in healthcare. Data from the ONC even recently revealed that interoperability advances among office-based physicians stalled between 2015 and 2017.
Providers and other stakeholders seeking relief from prior authorization burdens face a similar scenario. According to CAQH, a lack of connection between administrative systems that originate DME prior authorization requests and clinical systems that have supporting evidence is a barrier to end-to-end automation.
Solutions Are Limited to Those That Support the Standard Transaction
According to CAQH, providers have few options for purchasing vendor solutions that can automate the DME prior authorization process from start to finish. In the 2017 CAQH Index, the council discovered that only a few vendor solutions could enable electronic DME prior authorizations. Only 12% of items were capable of handling electronic prior permission, compared to 74 to 91% for all other electronic transactions studied.
Manual Intervention Is Required In Certain States
According to CAQH, several states need aspects of the DME prior authorization procedure to remain manual. When a prior authorization request is not certified, health plans in Minnesota, for example, must contact providers by phone, fax, or secure email.
According to CAQH, both Colorado and Rhode Island require health plans. It is to give physicians the option to talk with a qualified medical expert over the phone or in person before issuing an adverse DME prior authorization finding. The state rules are intended to ensure that patients with more complex DME prior authorization requests receive the best possible care from their doctors and health plans promptly.
The states, on the other hand, keep the process stuck in the manual world, imposing difficulties on both providers and payers. Furthermore, having to comply with manual prior permission rules in some states but not others creates distinct issues for health systems and plans across the country, according to CAQH.
Awareness of Providers
CAQH contends that a lack of provider understanding that HIPAA mandates health plans to send the 5010X217 278 Request and Response. As the DME prior authorizations are inhibiting the industry from embracing electronic transactions on a larger scale.
Key takeaways
CAQH hopes that now that the key difficulties have been highlighted, parties will work more collaboratively to establish and implement an electronic standard for DME prior authorizations. Every standard and operating rule development organization has a piece of the puzzle that must be put together to combine clinical and administrative data.
These organizations are collaborating more closely than ever before, recognizing the significant possibility to optimize the DME prior authorization process. To close automation gaps, new projects are focusing on the interaction between standards and operational regulations.
