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How One Payer Is Simplifying Prior Authorization. Will it Make a Difference?

Analysis  |  By Marie DeFreitas  
   October 28, 2024

A partnership between Blue Shield of California and Salesforce aims to dilute some prior authorization struggles for providers.

Blue Shield of California is teaming up with Salesforce to ease the burden of prior authorization for providers. 

The nonprofit health plan will aim to use its prior authorization platform solution on Salesforce Health Cloud to work within physician systems. The platform will gather relevant clinical data from EHRs and disparate systems, allowing members and physicians to get prior authorization in near real-time.

After a physician prompt, the platform will search a patient's EHR for relevant clinical information and compile an electronic document. Physicians will then be able to submit requests from their systems at that moment and members will receive answers during their medical appointments. Modifications or denials will always be made by a medical director or licensed clinician. 

Testing for the platform will begin in early 2025, with limited rollout later in the year, and near real-time prior authorization will be available starting January 2026.

"As a practicing physician, I'm proud that we're taking on this challenge to build a solution that allows providers to focus on delivering care — why they became physicians in the first place — rather than adding to the administrative burden," said Ravi Kavasery, M.D., chief medical officer, Blue Shield of California, in a press release.

The Prior Authorization Battle

Prior authorization is one of the biggest challenges for providers, often leading to a long, tedious administrative process and worse health outcomes for patients. According to an annual survey by the American Medical Association, 78% of physicians say issues with prior authorization can lead to patients foregoing care.

Part of this challenge also stems from outdated and inefficient industry processes While new technology like AI and automation have played a role in streamlining industry processes, AI has also been used on the payer side to deny care.

Another question coming out of this partnership is: whether other payers will follow in the footsteps of Blue Shield of California or find other ways to ease the prior authorization process.

The CFO Toolkit

The partnership between Blue Shield of California and Salesforce, while innovative, is just a drop in the bucket compared to the prior authorization struggles of providers all across the country.

CFOs should still prepare for continuous claims struggles with payers, and ensure they are very carefully negotiating their system’s payer contracts and choosing the right payers for coverage. For some CFOs, implementing weekly payer meetings and conducting strict documentation has helped push back on some payer tactics for inappropriately denying care.

 

Marie DeFreitas is the CFO editor for HealthLeaders.


KEY TAKEAWAYS

Blue Shield of California is teaming up with Salesforce to ease prior authorization processes for providers.

Prior authorization has been a massive issue for health systems all over the country.

CFOs will still need to have an ongoing gameplan for their payer struggles.


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