Authorization

Traditional prior-authorization costs organizations over $82K per physician each year.
Learn how CareSelect can help automate authorizations for advanced imaging.

Payors deploy authorizations to manage advanced imaging utilization by requiring providers to demonstrate medical necessity to ensure appropriate care for members. Providers struggle to meet and justify the administrative burdens of prior authorization with 90% of provider claim prior authorization delay the delivery of care.¹ When CMS was confronted with rising utilization, instead of implementing prior authorization for Medicare beneficiaries, CMS opted to use clinical decision support based on appropriate use criteria.

Immediate Opportunities

90% of providers cite care delays due to prior authorization. 75% of providers report that the burden of prior authorization is high or extremely high.¹

Delivering appropriate use criteria (AUC) through order entry decision support has proven to curb over-utilization, guide providers to appropriate care, and demonstrate clinical utility. Many healthcare organizations are already leveraging their CareSelect implementation to obtain “gold card” exemptions from prior authorization for advanced imaging.

Healthcare organizations use CareSelect to demonstrate appropriate utilization to the payor to create the foundation for utilization self-governance like “gold-carding.”

The University of Virginia (UVA) Health System examined the utility of clinical decision support and quantified its impact in a recent peer-reviewed article. They used their results to negotiate with a major state-wide payor to obtain Gold Card status and automate their authorization workflow through CareSelect.

Automate any prior authorization,
independent of content.

Integrate

Align payors and providers with common evidence-based criteria, integrated into both workflows.

Automate

Reduce inefficiency by automating routine medical reviews, authorization requests, and determinations.

Collaborate

Enable payors and providers to collaborate on complex cases and manage by exception.

Transform Utilization Management

Reviewing prior authorization requests is a time-consuming, manual process, which can take a provider anywhere from 10-30 minutes for a typical request. Most of the clinical data needed is housed in the provider’s EHR and payors receive this information as faxes, phone calls, or files uploaded to a portal. This inefficient process consumes provider and payor staff time, which could be better spent managing patient care.

Advances in technology and adoption of industry standards are setting the stage to fundamentally transform utilization management from a predominantly manual, expensive, and burdensome process to one that is automated, exception-based, proactive, and informed by clinical data.

The Role of CareSelect

CareSelect is essential to aligning provider care decisions with extracted EHR encounter data against payor authorization criteria.

In January 2018, NDSC became a Change Healthcare Company, following a collaboration to enable InterQual AutoReview™ through our technology. Change Healthcare’s InterQual^® team utilized CareSelect technology and guideline authoring ability to deliver the team’s comprehensive clinical criteria to the point of care.

The Change Healthcare InterQual team used the CareSelect platform to deliver industry-leading clinical criteria to the point of care, leveraging real-time access to clinical data. This streamlines utilization management and authorization processes, which today are labor-intensive, redundant, and expensive.

As Change Healthcare, we are expanding content delivered through our solution to enable the vast range of payor-facing criteria and connectivity capabilities of Change Healthcare in order to fully automate the prior authorization process through our EHR guideline delivery capabilities. Through CareSelect, we can enable any content regardless of source within the EHR workflow in order to inform the authorization process with the necessary clinical, administrative and financial data directly from the EHR.

Our Vision

Standards Based
Native workflows that leverage EHR integration points to ensure interaction

EHR & Payor Workflow Integrations
Supports automation across health systems
Content based on health plan requirements

Protected & Compliant
Only shares data necessary for decision without exposing proprietary information

Data for Prior-Authorization
Clinical encounter data is available directly from the EHR