Emblem Health’ s chief financial officer knows that prior authorization — where patients have to get advance clearance for a procedure from their insurance companies through their providers — can be frustrating. But in an interview at the Total Health conference organized by Reuters Events in Chicago on Thursday, she rejected the notion that the system is pernicious because it was designed to delay care and cause patient harm, as the American Medical Association has charged.

Instead, Heather Tamborino believes that the intent behind prior authorization is a good one.

“I think elements of prior authorization have been critical – it helps us prevent fraud, waste and abuse, it helps us to get care-related data for our members to make sure that they are getting access to the care they need to get access to,” she said in an interview.

Emblem Health is one of the nation’s largest nonprofit health plans and is based in New York City. It serves more than 3.2 million members.

While Tamborino’s point about “fraud, waste and abuse” is the defense that the insurance industry’s lobby group AHIP has forwarded with respect to prior auths, Tamborino said that even without Congressional scrutiny, Emblem Health is engaged in an ongoing process to review its prior authorization processes.

“I know for a fact that we are consistently looking at ‘what are those services that require prior authorizations around?’ are they necessary? do we approve them 99 % of the time, 95% of the time?” she said.

Asking the questions helps to determine whether the prior auth requests are coming from high-quality providers and looking for ways that they can be approved in real time.

“We are setting up capabilities for providers to do that digitally and through the portal so that speeds up the process for everybody,” she said.

That is something that even Congress is looking at. A bill mandating electronic prior authorization for Medicare Advantage plans has passed the House of Representatives. Besides mandating the adoption of electronic prior authorization, the bill also requires greater levels of transparency, approval rates, and rationale for denied requests. The bill was introduced in October 2021 by ​​U.S. Senator Roger Marshall, M.D. (R-Kansas) as a way to “prioritize patients over paperwork.”. Since its introduction, it has been lauded for winning bipartisan support and more than 500 organizations representing patients, physicians and hospitals have endorsed it. If the Senate approves the bill as is expected,  it would then be codified into law by the Centers for Medicare and Medicaid Services perhaps as early as 2023. 

If implemented, it will speed up the process significantly. Even AHIP found in 2021 that electronic prior authorization that can reduce the mean time from PA request to decision by 69%.

“We are focusing on the digitization of it because if you think about it, there’s no benefit to a payer or insurer to delay something for seven days. We are still going to provide this service and it’s still going to cost us,” Tamborino pointed out. “It’s a legacy process … and not an efficient process versus an intent to deny care.

Photo: Piotrekswat, Getty Images