CAQH CORE Urges Industry Wide Collaboration, Immediate Measures to Improve Prior Authorization Process

In letter to authors of the Consensus Statement on Improving Prior Authorization, CAQH CORE highlights areas of agreement, opportunities to address burdens on healthcare providers, health plans and patients

WASHINGTON, DC - 7/26/18

The Board of CAQH CORE®, a collaboration of more than 130 public and private entities across the healthcare industry, today released an open letter to the authors of the Consensus Statement on Improving the Prior Authorization Process, which include the American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), American Medical Association (AMA), American Pharmacists Association (APhA), Blue Cross Blue Shield Association (BCBSA) and Medical Group Management Association (MGMA). In the letter, the CAQH CORE Board endorses the statement and urges ongoing cooperation to reduce healthcare costs, ease administrative burdens and improve continuity of care and the patient experience.

“We are greatly appreciative of the consensus statement authors’ commitment to this critical issue,” said Robin J. Thomashauer, President of CAQH. “CAQH CORE participating organizations have spent considerable time developing ways to promote greater automation in the prior authorization process. We agree wholeheartedly with the consensus statement, and are eager to work together to make a difference.”

The letter highlights specific areas where CAQH CORE and the organizations that authored the Consensus Statement have clear, shared goals such as improved transparency and communications, continuity of patient care and greater automation and efficiency. For example, Phase IV CAQH CORE Operating Rules set industry expectations for how prior authorization data is exchanged through requirements for response times, connectivity, acknowledgement of requests and real time and batch processing. When finalized, Phase V CAQH CORE Operating Rules will ensure electronic prior authorizations contain critical information needed by providers and health plans to reduce the need for manual follow-up.

Citing the 2017 CAQH Index, the CAQH CORE Board notes that prior authorization is clearly in need of support. Adoption of the standard prior authorization transaction (ASC X12N 278) by health plans and healthcare providers could result in savings of $6.84 per transaction, one of the most significant per-transaction opportunity areas. However, the proportion of prior authorization transactions conducted using that standard actually declined by more than 10 percentage points in comparison to the 2016 CAQH Index. 

“CAQH CORE has made significant progress identifying and addressing some of the technical challenges associated with prior authorizations, but there is more to be done,” said Susan L. Turney, MD, MS, FACMPE, FACP; CAQH CORE Board Chair and President and CEO of Marshfield Clinic Health System. “If we can work together to improve the prior authorization process, we can reduce unnecessary manual interventions, cut costs and, ultimately, improve the efficiency and overall quality of patient care.”

Read the CAQH CORE open letter to the authors of the Consensus Statement on Improving the Prior Authorization Process.

About CAQH CORE

CAQH CORE is a nonprofit collaboration of over 130 public and private health plans, hospitals and health systems, vendors and other stakeholders across the industry. Through this collaboration, CAQH CORE helps stakeholders uniformly adopt electronic transactions and exchange data efficiently. Since 2005, CAQH CORE has developed and issued four phases of operating rules that support standards, accelerate interoperability and align fee-for-service administrative activities among providers, payers and consumers. In 2015, the CAQH CORE scope expanded to include exchange needs for value-based payment. www.caqhcore.org.

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