Across the industry, the current state of utilization review and management is too often a barrier to good health. While prior authorizations are intended to ensure compliance with evidence-based practices, they can be an obstacle to appropriate care, delaying diagnosis and treatment.
Ninety-four percent of physicians report prior authorization has caused delays in accessing necessary care. More than nine in 10 physicians said that prior authorizations can have a negative impact on patient outcomes. These delays and negative impacts directly translate to increased stress and frustration for patients, who often face lengthy wait times and struggle to understand the rationale behind authorization decisions.
“Utilization management in its current form is the antithesis to a remarkable health experience — it’s a pain point for patients, doctors, health plans and the government,” says Tony Farah, MD, FACC, FSCAI, chief medical and clinical transformation officer. “At Highmark Health, we’re on a mission to make the health care experience simple and seamless for providers and customers.”
In this article, Dr. Farah and Tim Law, DO, MBA, chief medical officer and vice president of integrated care delivery at Highmark, share how the health plan takes a fundamentally different approach to utilization management by collaborating with providers on shared goals for improving care and controlling costs. Learn more about how Highmark’s Gold Carding and Active Gold Carding programs are improving the prior authorization process for everyone.
Dr. Tony Farah
Dr. Tim Law
"Highmark is the only payer in the industry that grows ins Gold Carding program through direct engagement with providers. Fostering close collaboration with providers is key to our success."
CHIEF MEDICAL OFFICER & CLINICAL TRANSFORMATION OFFICER HIGHMARK HEALTH
Catherine Clements: We know that prior authorization and other aspects of payer utilization management are pain points for many providers. Can you start by talking about why utilization management is necessary?
Dr. Tim Law: Utilization management is necessary because, as a health plan, we have two responsibilities: a medical responsibility to our members to make sure they get appropriate care at the right time and place, and a fiduciary responsibility to the people that pay premiums, like employers.
Whether the health plan is involved or not, most doctors are prescribing the right things — and for that population of clinicians we want to stay out of their way.
On the other side, doctors may need some guidance or support eliminating procedural errors on authorizations. For example, a simple mistake like ordering a cardiac test with contrast when it's not needed can lead to delays and unnecessary costs. Through our health plan data, we’ve found that a significant percentage of denials are attributed to administrative errors as opposed to poor medical decision making.
Catherine Clements: Dr. Farah, what challenges are top of mind for you?
Dr. Tony Farah: Prior authorizations are costly and are associated with a significant administrative burden. Providers request an average of 45 authorizations per physician per week — that’s the equivalent of two days of physician and staff time.
These slow, complex authorization processes allow for tens of millions of dollars of waste in the health care system. It’s our responsibility, and it’s consistent with our Living Health strategy, to eliminate the barriers that get in the way of having a remarkable health experience for everyone involved.
Dr. Tim Law: The remarkable health experience isn’t just for members — it’s for providers too. We're trying to make the whole system better for everybody. When providers are supported and satisfied, they can focus on delivering the best care to their patients.
Catherine Clements: Variation in care still exists, despite widely endorsed evidence-based guidelines. How are we addressing this?
Dr. Tony Farah: Health plans should not be in the business of telling physicians how to practice medicine — we understand that, and I’ve been a big voice in that. But clinical variation is present across the country, even at the most sophisticated health systems. Most of the clinical variation I would put in the confines of the art of medicine, because we treat every patient that we see based on their individual conditions and attributes. That’s not the kind of variation we are trying to reduce — we want to reduce variation that goes beyond what most physicians agree should not be taking place, and that really doesn’t adhere to evidence-based guidelines.
Catherine Clements: In recent years, Gold Carding has emerged as a tool to streamline prior authorization. Can you tell me more about Highmark’s Gold Card Program?
Dr. Tim Law: Gold Carding is a transformative way to do utilization management. It removes some procedural requirements, allowing for a shorter timeframe between diagnosis and treatment. At Highmark, providers are Gold Carded once they reach a high level of adherence (99%+) to evidence-based clinical care guidelines. This eligibility criteria can vary in accordance with state mandates and does take into account certain patient-to-patient variations that arise in many areas of medicine.
Once Gold Carded, providers only submit a prenotification to schedule services — no clinical information is needed, and approval is granted immediately. Providers can expect up to an 85% reduction in administrative processing time. That means less need for peer-to-peer reviews and more time for patient care. By providing instant approval at the point of care, Gold Carding eliminates the need for phone calls, emails, and delays. Patients leave your office knowing their treatment is approved and that the test or procedure can be promptly scheduled. Doctors are eager to participate in this program because they want appropriateness of care to be an outcome for them while simultaneously reducing administrative burdens.
Catherine Clements: How does the adherence rate (99%+) we set as an organization compare to other Gold Card programs?
Dr. Tim Law: Our standard is above that of the industry. The 99th percentile gets us to the point where the doctor is truly performing — providing the right care for their patients nearly all the time. We believe every clinician can and should be Gold Carded — and we’re going to help them get there. That’s why we’re collaborating directly with clinicians to provide a pathway to get them to 99% through our Active Gold Carding Program.
Some states mandate Gold Card approval based on a threshold of 80-90% appropriate care. That means you’re willing to accept suboptimal care, whether it’s clerical or bad medicine, for up to 20 out of every 100 people. Simply setting a minimum threshold for specific modalities is not enough.
Dr. Tony Farah: That low of a threshold won’t move the needle on improving health outcomes, and it doesn’t alleviate the burdens that we’re talking about.
Dr. Tim Law: Right, to create a remarkable health experience means improving the health of the community that you’re serving from both the provider and health plan side. If you get too low approval rates, you’re propagating suboptimal care, and that’s not what we want to do.
Catherine Clements: How has Highmark grown and scaled its Gold Card Program?
Dr. Tim Law: We initially launched Gold Carding in January 2022, expanding in May 2023 for a total of 400 providers. As of September 2024, we’ve grown the program to more than 21,000 Gold Carded providers. More than half of those providers are Gold Carded for two or more modalities. This is important, because if you’re only Gold Carded for one modality, that’s not going to reduce the administrative burden of the practice.
In the last 12 months, we’ve had over 400,000 authorizations submitted by our Gold Carded clinicians. We’ve also reduced our cost to process an authorization significantly, allowing us to manage more and pass savings to members.
Catherine Clements: What sets Highmark’s Gold Card Program apart from the industry?
Dr. Tim Law: Where Highmark is differentiating is by constantly evaluating modalities to add to the Gold Card Program. Other organizations set their top codes and stop there. Instead, we’re continuously refreshing codes based on our data and direct clinician input. We’re also leading the industry through our Active Gold Carding Program.
Catherine Clements: Direct clinician input — that is a significant differentiator from other health plans. We have clinician leaders at the table to help shape these decisions. We’ll dive deeper into Active Gold Carding next. But first, tell me more about where we’re at with automation and electronic submissions?
Dr. Tim Law: For modalities clinicians prescribe correctly 100% of the time, we’re automating it. Before electronic submission of authorizations, there were a lot of phone calls and faxes. We’re aiming to get to 70% of authorizations submitted electronically by 2025. Once we get practices to adopt the portal, we can move forward quickly, positively impacting the bottom line and providing quicker care. We’re trying to think outside the box to get as much off the doctor’s plate as we can so that they can focus on taking care of patients.
Dr. Tony Farah: Automation for authorizations and Gold Carding go hand in hand. You can automate the existing process and not Gold Card a single physician — if we don’t actively Gold Card physicians, we won’t address the appropriateness. It’s just not enough.
Catherine Clements: What modalities are included in Highmark’s Gold Carding Program?
Dr. Tim Law: We’re expanding the program to include additional modalities, and it’s good to check our provider resource center for up-to-date information. As we speak, physicians are eligible to be Gold Carded for 14 different modalities, including CT, ECHO, MRI, pain injection, nuclear medicine, PET/PET CT, diagnostic heart cath and more. We believe we’ll soon be the first health plan in the country to actively Gold Card for neuro spine surgery, laminotomy, laminectomy and single level fusions. Expanding Gold Carding for inpatient care, post-acute care, behavioral health, and pharmacy are also on our roadmap.
Catherine Clements: Can you give me an example of how the streamlined authorization process makes a difference for patients and clinicians?
Dr. Tim Law: Absolutely. One of the first codes we added to the Gold Carding Program was pain injections. Streamlining this approval process helps prevent patients from resorting to opioids because they can’t get timely pain injections. By removing unnecessary barriers for appropriate pain management, we can reduce avoidable opioid prescriptions.
Additionally, the way we manage cancer tracking and diagnosis is positively impacting the experience for patients and clinicians. For instance, we know that in the post treatment of lung cancer, a patient needs to have six PET scans over a course of two years. Instead of requiring authorization for each scan, we’ll say, when you ask for this PET scan for this lung cancer, you get approved for six PET scans over the next 24 months. We’ve granted authorization for all six, do them when you need them. Let’s leave medicine in the hands of the doctors.
Catherine Clements: Gold Carding is a step forward in utilization management, but it doesn’t solve the root problem of why authorizations get denied. Dr. Farah, how is Highmark addressing this?
Dr. Tony Farah: We’re focused on educating and empowering providers to get prior authorizations right through what we call Active Gold Carding. This approach actively engages providers to ensure they are submitting accurate and clinically appropriate requests, thereby reducing denials and streamlining the process. The process involves providing them with actionable information, enabling them to improve their ability to achieve this level of performance.
Dr. Tim Law: Active Gold Carding is where we look at not only those providers that meet the metrics for instant prior authorizations, but those that are getting close. We leverage a concierge nurse to provide real-time feedback and live in-person or virtual coaching to help practices avoid denials and improve authorizations.
Dr. Tony Farah: Highmark is the only payer in the industry that grows its Gold Carding program through direct engagement with providers. Fostering close collaboration with providers is key to our success. Our unique structure as a blended payer-provider health organization allows us to provide valuable insights for our providers to maximize positive health outcomes.
From our perspective, there should be no reason why all physicians aren’t Gold Carded. By creating a pathway to Gold Carding, Highmark helps to improve patient and clinician experience and access to care while reducing avoidable costs.
Catherine Clements: How have we deployed the Active Gold Carding Program?
Dr. Tony Farah: Last year, we piloted the program with 250 Allegheny Health Network (AHN) providers, simply explaining our Active Gold Carding concept and tracking performance based on claims, volume, and appropriateness data. In just a few months, request volume decreased. This demonstrated that providers are motivated to proactively engage in solving the prior authorization problem.
Dr. Tim Law: As of September 2024, we have more than 1,200 clinicians in the Active Gold Carding Program. Some have already graduated into the Gold Card Program. We're getting ready to expand even farther across our footprint.
Dr. Tony Farah: We’re initiating Active Gold Carding first with our strategic provider partners such as Allegheny Health Network, Christiana Care, Penn State Health, Lehigh Valley Health Network and the Great Lakes Integrated Network.
Catherine Clements: What’s on the roadmap for further innovation and improvement in utilization management?
Dr. Tony Farah: We’re exploring a partnership with an organization specializing in cancer care to establish value-based, standardized protocols, in collaboration with doctors, for cancer treatment. This partnership represents a significant advancement in the utilization management process for cancer, offering a more efficient and patient-centered approach.
Dr. Tim Law: We are working to expedite and automate prior authorization processes to the point that they are seamless and occur behind the scenes for a provider. We have a robust roadmap for further scaling our automation authorization capabilities using AI and machine learning, while integrating the authorization experience within the electronic medical record.
Dr. Tony Farah: We’re really excited about the direction we’re headed. We have the vision, the team, and the roadmap in place to create a differentiated experience for patients and clinicians. While we’re just one payer, we’re committed to making our interactions with providers stand out. We believe that by focusing on a truly exceptional experience, we can contribute to a better health care system for everyone.
By: Catherine Clements
Originally Posted: September 27, 2024 on Highmark Health
This article was first published in Highmark Health Digital Magazine and is used with permission.
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