For the previous a number of weeks, Healthcare Innovation has been placing a highlight on the progress that well being plans and suppliers are making to adjust to the CMS Interoperability and Prior Authorization Remaining Rule to be able to enhance transparency and effectivity. We’re additionally taking a look at a number of the methods AI is impacting the prior auth interactions. In an e-mail Q&A, Tracy Alvarez, vp of Medical Care Options for Blue Protect of California, described the group’s effort to scale back supplier and member abrasion round prior authorization. The nonprofit group has 6 million members, over 6,500 workers and greater than $27 billion in annual income.
Healthcare Innovation: In a latest WEDI survey in regards to the challenges of assembly CMS interoperability necessities round the usage of FHIR software programming interfaces (APIs) for prior authorization, well being plans respondents mentioned their high considerations are digitizing insurance policies, assembly compliance timelines, and delegated third events dealing with challenges with totally different methods. Would Blue Protect say these considerations talked about within the WEDI survey align with the problems it sees as high of thoughts? As an example, do you might have an answer for digitizing all of your insurance policies for prior auth? Or are there different points you’re working by means of?
Alvarez: Plans that haven’t begun planning or implementing the digitization of insurance policies might certainly be pressed to conform by 1/1/27. At Blue Protect of California, our purpose is to scale back supplier and member abrasion round prior authorization. This isn’t a easy activity, and we’ve had a number of pivots in our method alongside the best way.
We’ve been designing our mature and scalable answer to digitize all medical insurance policies, together with prior authorization insurance policies, for a number of months. Our centralized medical coverage repository will seize all insurance policies in a machine-readable format versus PDFs so we’ve a single supply of fact that may be constantly interpreted throughout platforms. Digitization will even enhance automation for these remedies that want assessment, leading to sooner solutions for members and suppliers.
One other alternative is to make interoperability options extra precious for suppliers. We’re prioritizing information engineering work behind the scenes that may let suppliers know precisely when an authorization is required and likewise information and assist them by means of their prior authorization requests.
HCI: Blue Protect introduced it was going to work with Salesforce on a previous authorization answer. Are you able to describe the progress to this point on standardizing this digital prior auth platform? What points should be labored by means of earlier than its launch?
Alvarez: We’ve accomplished growth work with Salesforce, which can function our prior authorization interoperability hub to attach suppliers, payers, and specialty healthcare providers. We’re additionally about to launch our digital entrance door to a choose group of suppliers, which can assist them in submitting prior authorizations inside their current workflows. We need to meet suppliers the place they’re, so we’re taking what we study with this group and making use of it as we scale to extra suppliers.
HCI: Is there a task for AI in automating a number of the course of?
Alvarez: There’s a function for synthetic intelligence to automate some handbook prior authorization processes to hurry time to care. Blue Protect’s answer intends to assist human scientific critiques by creating determination bushes that robotically authorize care when all the required information is current. Blue Protect is simply enabling synthetic intelligence-powered capabilities to approve care, route prior authorization requests for clinician assessment, and current all the related scientific info to a doctor or licensed scientific skilled to make an evidence-based care dedication. We’ll by no means let synthetic intelligence expertise deny care. It’s California legislation that synthetic intelligence expertise can’t be used to robotically deny, delay, or modify care, and we additionally consider it’s the suitable factor to do.
HCI: Does Blue Protect have a venture staff and/or a supplier associate that it’s working with on the FHIR API growth and testing?
Alvarez: Blue Protect started our journey in mid-2024 to create a complete prior authorization platform answer as a result of we acknowledged the significance of making certain our members obtain evidence-based care in a well timed method. We created a devoted staff of quite a few leaders, technical leads, expertise companions, and different scientific stakeholder teams who’ve been diligently growing Prior Authorization Reimagined for our suppliers and members with FHIR APIs. We’ve additionally partnered intently with a serious supplier in California all through our portal growth and testing phases to make sure what we’re constructing works seamlessly inside the supplier workflow. At this level in our growth, we’re assured that we are going to be compliant with the CMS mandate for 1/1/27.
HCI: On the supplier facet, do the EHR distributors should make adjustments to their methods for the prior auth APIs on the payer facet to be put to good use?
Alvarez: EHR distributors are ready to enormously enhance the supplier expertise by enabling authorization requests to entry and leverage scientific notes inside the suppliers’ workflow. Such enhancements would guarantee Blue Protect and different payers obtain the information we have to make a previous authorization dedication, whereas minimizing administrative burden for the supplier to allow them to deal with affected person care. Recognizing some suppliers’ EHRs might not have this performance, Blue Protect additionally accepts prior authorizations by means of supplier portals and different channels to be able to meet suppliers the place they’re.
HCI: The rest you want to say about your expectations for the way these tech and coverage options will easy the prior auth processes?
Alvarez: We consider that to easy prior authorization processes, payers have to prioritize extra than simply compliance actions. The way forward for prior authorization is accuracy, effectivity, and approval of evidence-based care on the primary attempt.
In growing Prior Authorization Reimagined, we realized that eradicating current handbook processes from prior authorizations requires a extremely complicated answer. As is the case when creating new options, every iteration of supply and testing supplies alternatives and concepts for the way to operationalize a brand new system for prior authorizations, so members constantly obtain care in a well timed method.
As soon as we’ve our basis, we are able to then deal with delivering a extra customized, high-tech and high-touch prior authorization expertise for our members that features numerous communication applied sciences and join members to further well being care and providers.
HCI: Are there ways in which larger interoperability between payers and suppliers can be utilized for different use circumstances round member identification, engagement and cost? Or for value-based care applications?
Alvarez: Sooner or later, larger information sharing between payers and suppliers might enhance identification and determination of suspected care gaps, transparency of reimbursement insurance policies and out-of-pocket prices for members and finally function a foundational functionality for the long run imaginative and prescient of real-time claims achievement.
HCI: In 2025, Blue Protect made some commitments round prior authorization. Might you present any updates or larger element about any of the next? The primary is standardizing supplier submissions for digital prior authorization, giving medical doctors extra time for sufferers by lessening administrative burden.
Alvarez: Blue Protect of California is dedicated to streamlining prior authorization workflows to make sure a extra environment friendly and clear course of, whereas sustaining essential evidence-based care requirements for members. We introduced our intentions in October 2024. In 2025, we signed on to the AHIP commitments with different Blue Cross Blue Protect Affiliation plans. We consider realizing these commitments will end in considerably improved prior authorization experiences for our members.
HCI: The second is additional lowering the usage of prior authorization for sure in-network medical providers by 2026.
Alvarez: Whereas we actually goal to scale back the amount of prior authorizations, we actually see a larger alternative to extend the automation of handbook prior authorization processes and make extra prior authorization determinations in actual time, which can guarantee our members have entry to well timed, evidence-based care once they want it.
This 12 months, Blue Protect of California will even proceed to advance what we’ve already completed to scale back necessities for prior authorizations for members with established, ongoing wants associated to power circumstances.
HCI: The third is making certain a seamless course of for members who change medical health insurance corporations by honoring their earlier medical health insurance firm’s prior authorization approvals for benefit-equivalent in-network providers as a part of a 90-day transition interval, by 2026.
Alvarez: Blue Protect of California’s Continuity and Coordination of Care Program is designed, partially, to advertise steady and applicable care and supply well timed assessment and authorization for members needing ongoing remedy, when care disruptions might in any other case happen.
Our program ensures that members with complicated, power, or acute wants, in addition to these requiring maternity, pediatric, or specialised gear/providers, expertise seamless transitions and uninterrupted care throughout supplier or plan adjustments, and absolutely adheres to all state and federal necessities for continuity of care.
HCI: One other purpose is making the method extra clear by making certain communications to members about prior authorization are clear and include customized info, together with what is required to assist approval, subsequent steps and accessible attraction processes.
Alvarez: Transparency in communications to members about prior authorization is a cornerstone of Blue Protect’s method. We goal to empower members to extra effectively navigate subsequent steps in care by offering clear, individualized, and consumer-friendly notices about prior authorization choices. By making the explanations for any non-approval clear and actionable, our method is designed to speed up scientific follow-up. We additionally frequently replace scientific pointers and prior authorization lists on supplier portals and public web sites, so our members, suppliers, and companions are conscious of present prior authorization necessities.
HCI: One other is fast-tracking responses for digital prior authorization requests by committing to answering at the very least 80% of requests in close to real-time in 2027.
Alvarez: Blue Protect’s Prior Authorization Reimagined initiative goals to streamline the prior authorization course of for suppliers and members. This 80% metric is vital to lowering abrasion within the system and requires the profitable completion of many actions. We at the moment have the inspiration in place that checks if an authorization is required by parsing in real-time: prior authorizations on the requested remedy, member eligibility, enterprise guidelines, and digital consumption automation. To get us to the 80% auto approval fee, we’re working with business companions to develop and deploy further determination tree (DTR) capabilities. We’ve already coded a big variety of medical insurance policies as a part of this effort.
HCI: The ultimate one is affirming that licensed physicians personally lead critiques of unapproved prior authorization requests.
Alvarez: Blue Protect solely has certified licensed professionals (QLPs) assessment supplier requests for well being care providers. Moreover, QLPs consider these scientific points that align with their scientific space of experience. When needed, specialty peer assessment evaluations could also be requested and returned to the Medical Director for assessment and closing dedication.
