Epic, Oracle and Cleveland Clinic among companies to joining CMS prior authorization initiative

A slew of provider and tech organizations have signed on to the Centers for Medicare and Medicaid Services’ push to streamline prior authorization, a transition the agency said will smooth out the bumps of a widely loathed payer practice. 

As teased in a blog post last week, CMS and its administrator, Mehmet Oz, M.D., announced Wednesday that 29 healthcare organizations have agreed to tackle the workflow, technical and operational issues that have hampered adoption of electronic prior authorization—or digital exchange of coverage requests as opposed to letters, faxes and phone calls.

Nine of those organizations are major insurers that, for the most part, had pledged to do so last year, including UnitedHealthcare, Cigna and Aetna. The remaining 20 are a mix of health systems such as Cleveland Clinic, Sanford Health, Providence and Ochsner Health; electronic health record vendors such as Epic, Oracle and athenahealth; and data networks like eHealth Exchange and b.well Connected Health. 

Oz described the pledges Wednesday afternoon in a fireside chat at the Axios Future of Health Summit, telling the audience that while insurance companies “have been playing ball” with CMS on the issue there had been less participation from providers. 

“Fifty percent of prior auth questions are sent back by fax,” he said. “It’s very inefficient, often is delayed, is lost, confusing, doesn’t get correlated right, it doesn’t get exchanged back and forth, you take scans of fax pages—it’s just dumb. We should just ax the fax.” 

Specifically, the 29 “early adopters” highlighted by CMS have agreed to work toward integrating electronic prior authorization into their clinical and administrative systems. They’ve also committed to reducing their reliance on manual processes, like faxes; increase visibility in the status of an authorization query and broadly improve information handoffs at a technical level, the agency said.

CMS has also engaged in rulemaking that requires specific interoperability and prior authorization timelines to be implemented by a Jan. 1, 2027, deadline. 

Should these various efforts come together, Oz said, come January, “there will be some settings where you will have a prior auth done and you will not know it happened, because the insurance company will query the EMR of the hospital or doctor’s office that you’re in, it will automatically pull the data out to justify that you actually need that mole to be biopsied. Your doctor doesn’t spend any time, you don’t spend any time, the insurance company doesn’t spend any time. This is billions of dollars wasted every year.”

Recent weeks have seen individual insurers and their associations touting their progress on standardizing electronic prior authorization requests—an 11% reduction in prior authorization volume among leading health plans, or 6.5 million fewer requests, and a larger 15% reduction within Medicare Advantage specifically. 

Blue Shield of California—which had made commitments last year as a member of AHIP and the Blue Cross Blue Shield Association, but has now officially put its own name to the early adopter pledge—said that moving beyond CMS' minimum requirements for multi-organization compatibility "is a step forward in addressing prior authorization as one of the biggest pain points in healthcare." 

Providers who are on the other end of that process have so far remained skeptical of the purported reductions. Health system executives and management teams have frequently cited elevated utilization management activity from payers as a headwind to their own performances, and survey data released this week by the American Medical Association found that only one in three physicians believe that the pledge made by insurers will bring a noticeable improvement. 

“Physician trust in voluntary insurer pledges is deeply eroded after years of unfulfilled promises,” AMA President Bobby Mukkamala, M.D., said in a statement addressing the survey findings. “Physicians are especially frustrated when so-called peer-to-peer reviews are conducted by individuals who lack the appropriate clinical expertise to evaluate a patient’s care. When only a third of physicians expect meaningful impact—and so few report that health plan reviewers are appropriately qualified—it highlights a credibility gap that won’t be closed with vague or partial measures.”