Regence, MultiCare Implement Nation's First FHIR-Driven Prior Authorization Standard

"Bringing pre-authorization to the point of care" reduces burden across stakeholders, notes one Regence executive.

Regence—a Blue Cross Blue Shield Association plan offering commercial, exchange, and Medicare Advantage (MA) plans across Idaho, Oregon, Utah, and Washington—has launched a partnership with ACO MultiCare to speed prior authorization (PA) using the FHIR PA Support Standard.

The new standard "will provide an interoperable method for providers to submit prior authorization requests directly from electronic health records at the point of care," said Regence in its press release.

In the release, Regence VP CTO Kirk Anderson states: "Bringing pre-authorization to the point of care reduces the burden on health systems managing patient data and promotes timely, evidence-based care and a more seamless experience for our members."

MultiCare's AVP of population health and value-based care, Anna Taylor, adds: "Embedding pre-authorization in our native EHR system is a gamechanger … Not only will we ease the administrative complexity of health care, but the ability to receive transparent and actionable data at the point of service accelerates care delivery and increases adherence."

PA automation

Other health plans are automating the PA process. But Regence reports that it is the first health plan to do so using a FHIR Application Programming Interface, or API, that will "enable faster determinations, reduced administrative burden and costs, and better outcomes for patients."

PA automation is one of several operational improvements possible by FHIR, definition including APIs. Two others include API-enabled patient data access and provider directory standards, required by CMS' Interoperability and Patient Access final rule. Payers offering MA, Medicaid, or CHIP plans were required to comply with the provider directory rule effective July 2021.

And while X-enabled PAs are not yet required—CMS' Interoperability and Prior Authorization rule was proposed in December 2020 but is not yet final—the Regence-MultiCare implementation reflects stakeholder understanding that FHIR-driven APIs are a key tool for making meaningful digital healthcare transformation a reality.

PA under fire

Health plans use PA to manage health service delivery. Ideally, PA prevents improper utilization and encourages appropriate, evidence-based care. Providers and patients alike, however, see PA's true intent as cost control that restricts access to needed services. Providers site the cumbersome PA process, one that often requires dedicated staff to manage, as a key contributor to the burnout worsened by the pandemic.

Congress agrees. In September, the House passed the Improving Seniors' Timely Access to Care Act, which requires MA plans to report their PA utilization rates to CMS, including resulting approvals and denials. The bill, also supported by the Senate, requires HHS to establish a "real-time" PA decision process facilitated by automation.

And while it only applies to MA plans, the bill­—combined with CMS' proposed interoperability rule—would create a path to PA progress that stakeholders have been calling for.