How Prior Authorization Brings Value to Patients and Their Health Plans

As the chief medical officer of eviCore healthcare, a medical benefits management organization within Evernorth Health Services, Dr. Eric Gratias and his team work to ensure that patients receive medical treatments that adhere to evidence-based clinical guidelines—which change rapidly and constantly.

One tool they use is prior authorization, a process that is often criticized for denying care—but is actually designed to protect patients by promoting the right care. Prior authorizations prioritize patient safety while improving health outcomes, always putting patient care first.

We sat down with Dr. Gratias to pick his brain on how the prior authorization process protects patients while helping physicians keep up with the rapid pace of clinical innovations and corresponding treatment guidelines. Read on to learn more about how eviCore helps patients get the care they need while avoiding unnecessary procedures that can cost them time, money, and peace of mind.

Tell me about eviCore.

eviCore is a data-driven organization devoted to guiding patients to the care they need, when they need it—and to steering them away from care that might be unnecessary or even harmful. We employ a large team of experienced medical professionals who utilize a blend of innovative technology and high-touch human engagement. For example, this often means that an eviCore physician reaches out directly to the treating physician to discuss the patient’s medical history and test results before rendering a decision on medical necessity. In addition, we reach out to patients to encourage them to schedule regular health exams and screenings or to explain their options when selecting a site of care—providing personalized choices based on cost, quality, and convenience.

Why is prior authorization in health care important?  

Prior authorization is a critical step in getting patients the best care possible. Today, the rapid pace of medical innovation is creating an unsustainable rise in health care costs and making it challenging for some clinicians to keep up with the latest research and developments. I experienced this firsthand when I was a practicing pediatric oncologist—and I’m not alone. More than two-thirds of physicians feel overwhelmed by the amount of information they need to keep up with. The blind spots that inevitably creep into all physicians’ knowledge base often lead to unnecessary or inappropriate care, some of which carries significant risk of harm for patients. In fact, approximately 20% of medical care delivered today is unnecessary.

Less-than-ideal or inappropriate care can lead to numerous issues, including inaccurate diagnoses, ineffective treatments, false positives, exposure to unnecessary radiation, and higher out-of-pocket costs. By keeping providers current on critical nuances in treatment procedures and clinical guidelines in the process of making decisions on care, we fill those gaps in knowledge. This ultimately protects patients from receiving unnecessary—and potentially harmful— care and enables the treating physician to identify and select a superior (and sometimes more expensive) care approach before the wrong care is delivered, helping drive down overall costs for health plans.

For example, over the last 2½ years we’ve saved patients with cancer from receiving about 64,000 unnecessary radiation treatments by ensuring they receive the latest evidence-based care. This makes a real and positive impact on a cancer patient’s quality of life. It means fewer medical visits, fewer missed days of work, less side effects, and less anxiety.

The prior authorization process has a reputation as being a way to deny care. Can you speak to that?

We aren’t in the denial business, we’re in the approval business. We’re focused on getting patients the right services and treatments that will actually help them—and we take that job very seriously. Sometimes the right care is exactly what was planned, and sometimes the evidence says that the right care is a little different than the original plan.  We truly are a critical safety net to make sure patients aren’t harmed by the inevitable blind spots that creep into physicians’ knowledge.

Who reviews eviCore’s prior authorization requests?

We have an incredible team of over 500 board-certified physicians—with thousands of years of clinical experience, collectively—who partner with providers across more than 60 specialties. Each of our doctors practiced clinically for a significant number of years before joining eviCore, and they continue to attend educational and quality improvement programs to stay current on the latest happenings in the industry and maintain continuous board certification in their specialties. Our clinical staff also includes more than 1,200 other clinical specialists, including nurses, genetic counselors, physical therapists, speech therapists, and others—all committed to delivering the best care for our patients, a mission that drives us all.

When we see a knowledge gap—for example, when the reviewing physician needs additional information or the treating physician may be unaware of updates in clinical guidelines—we set up a peer-to-peer review with an eviCore physician who is a specialist in the specific area under discussion. These are designed to be educational and collaborative, and the goal is to reach an agreement by the end of the call.

As a pediatric oncologist, I’ve been on countless peer-to-peer calls. I remember one specific case where I reached out to a pediatrician who had scheduled a CT scan for a young patient suffering from headaches. For background, a headache in a child under age 5 is almost always a reason for advanced imaging, and the best imaging choice for most patients is an MRI. But MRIs are more expensive than CT scans and require sedation, so doctors who don’t specialize in children with cancer may not realize the nuances and often start with a CT scan, which can delay care by days to weeks.

This potential delay is very concerning, as young children’s brain tumors can worsen rapidly when the diagnosis is delayed. That’s one of the reasons we quickly scheduled a peer-to-peer review. As I talked to the child’s pediatrician—who was not an oncologist—he was noticeably upset that we had denied the CT scan, not realizing we’d recommended an MRI instead. As we spoke, I shared how CT scans were less sensitive and wouldn’t pick up the images an oncologist would need if there was cancer, requiring a delay in care until the child received a follow-up MRI. The pediatrician quickly agreed. Frankly, he was surprised by our thoughtful approach to our work.

After our call, the child got the MRI quickly. That consultation probably shortened his path to a diagnosis by three weeks—and it saved the parents and child a lot of stress.

You hear a lot in the news about prior authorization being a burden for providers. What is eviCore doing to make the process more efficient?

No question, prior authorization needs to continue to evolve. The overall administrative burden for providers is too great, and prior authorization is only one component of that burden. This is a key focus area for us at eviCore—we’re working to simplify the authorization process so providers can spend less time on administration and more time with patients.

We’re doing this by leveraging multiple automation tools, including our intelliPath products, to make the prior authorization process easier and faster for providers and patients. Through intelliPath, we leverage a single easy-to-use application to integrate providers’ work streams with major electronic health record (EHR) vendors. This allows us to automatically pull relevant patient, provider, and treatment information, helping avoid the back-and-forth that sometimes happens when we’re missing a critical detail needed to make a decision.

Collectively, I’m proud that our efforts across the board are saving clinicians’ time. Today, we are able to determine approximately two-thirds of medical decisions in real time—and 90% of our approvals are completed in one business day, quickly putting patients on the path to better health.