Vanderbilt CEO: Healthcare system can fix prior authorization without waiting for payers
Jeff Balser, CEO of Vanderbilt University Medical Center, said the health system must take responsibility for situations where the prior authorization process is broken and stop deferring action to payers.
“A lot of the work, the time, the delays in prior authorization were actually borne by us,” Balzer declared at a panel meeting last week. Forbes” New York City Healthcare Summit.
He noted that once an appointment is scheduled, the provider can begin the prior authorization process. He explained that many rejections were not because the service was unsuitable, but because the provider failed to provide the correct information.
Balzer stressed that health systems need to support clinicians with better workflows and centralized teams so doctors don't do the job alone.
He also noted that AI could significantly reduce the burden of prior authorization. Vanderbilt is using machine learning tools in its clinics to surface exactly the information each payer needs to approve a request.
“The information that insurance companies need is all in the health record, so we actually started working on an AI process that could automatically collect the information needed for prior authorization and just have the clinician approve it so we’re not wasting everyone’s time,” Balser said.
Still, he noted, collaboration with payers remains critical. He pointed to two key areas where Vanderbilt is working closely with payers: standardization and gold cards.
Balcer said the health system is working with payers to make prior authorization requirements more consistent across plans and implement a policy that waives prior authorization for clinicians in clinical areas where approval rates are already extremely high. This approach, often called “gold card carding,” can eliminate thousands of unnecessary reviews and speed up patient care, he said.
Balser's co-panelist — Steve Nelson, executive vice president at CVS Health and president at Aetna — believes partnerships between payers and providers are not only possible but essential.
“There's a myth that payers and providers can't work together. I've led organizations in both areas, and I tell you that's not true. We don't despise each other,” Nelson declared.
As for Aetna's internal efforts to innovate its prior authorization process, he said payers are rolling out new bundles and better data exchange plans.
Instead of separate authorizations for drugs, procedures and follow-up care, Aetna now provides a single prior authorization for an episode of care, such as a round of in vitro fertilization, a cancer care journey or the management of a musculoskeletal condition.
Nelson also noted that Aetna is replacing “outdated” data exchange methods with faster, more accurate networks so that good decisions can be made quickly.
Photo: Andrii Yalanskyi, Getty Images
