A partnership with insurer Aetna has helped one academic medical center avoid traditional prior authorization requests in 69% of certain imaging orders, potentially sparing staffers from hours of busy work.
The University of Virginia Health System did so by deploying a clinical decision support system that guided ordering providers based on American College of Radiology appropriateness criteria. All told, physicians voluntarily used the tool on about 15% of orders, with Aetna granting immediate access to exams to facilitate faster patient care, experts detailed in JACR.
Based on previously published estimates, each authorization can cost providers about 16 minutes or upward of $100 to complete. At those rates, UVA may have saved some 266 hours or as much as $100,000 during its effort.
“The model used in this pilot program has significant potential to be replicated,” Cree Gaskin, MD, with UVA Health’s Department of Radiology and Medical Imaging, and colleagues wrote Jan. 28. “We are actively exploring the potential to expand this program to other private payers, and we believe it could be reproduced at a number of other institutions.”
One Kaiser Foundation study estimated that docs spend more than 868 million hours a year on prior authorization activities. Wanting to address this issue, UVA experts theorized that using a commercially available decision support tool, in concert with a payer, could expedite the process.
Both radiology and revenue cycle teams at the academic medical center began engaging Aetna and its radiology benefits manager on this idea in 2016. The effort finally launched in June 2018, with outpatient advanced imaging orders being ranked on a scale of 1-9 on their appropriateness. Aetna expedited the request if the order scored a 7-9 on the system, the patient was a member of its health plan, and the imaging was both ordered and performed at UVA.
Providers ended up ordering 9,640 imaging exams between June 2018 and October 2019 during the pilot. And about 15% of the time (or 1,453 exams), physicians voluntarily opted to use clinical decision support, with 69% (997) of those exams qualifying for expedited prior authorization. This meant that UVA was guaranteed to be paid for the exam the moment it was ordered, and radiologists could potentially perform scans the same day, without delays, Gaskin et al. noted.
After two years of using the CDS tool, all involved remain satisfied, and in February 2020 they began “substantial program expansion.” The health system elected to make use of the clinical decision support tool mandatory for all outpatient imaging orders at the time, including those in patients with only private health insurance.
You can read much more about the program in the Journal of the American College of Radiology here.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.