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May – June 2020
10 questions with Jeniene Edwards
 Jeniene Edwards, vice president of Utilization Management, had so much good information to share when we talked with her recently that we expanded our regular “5 Questions with…” feature to accommodate 10 questions.
1. Utilization management has been a hot topic in the health care industry over the past year. How would you define it?
In the simplest terms, utilization management is ensuring that our members get the appropriate care at the right time and the right place.
2. What role does prior authorization play in the utilization management process?
It’s one of three levers we can use in the broader utilization management process. The others include clinical editing and audit.
3. How do you make prior authorization decisions?
Medical necessity decisions are evaluated upon evidence-based guidelines, medical policies and supported by physician judgment.
4. What type of feedback do you typically get from health care providers about the utilization management process, particularly prior authorization?
While they may not like some of the processes we have in place, most providers understand the need for prior authorization. As Dr. Marc Keshishian pointed out in a previous column in this newsletter, a recent study found that waste in the system accounts for roughly one‑quarter of all U.S. health care spending, and we owe it to our members to try to address this problem.
5. How are you addressing the concerns of providers?
At Blue Cross Blue Shield of Michigan, we work hard to streamline the prior authorization process. Our average timeline for prior authorizations is extremely favorable compared to what regulatory requirements dictate. We also have put in place certain processes to streamline prior authorization. For example:
- We use what we call "gold carding" to exempt some providers from prior authorization if they meet certain criteria based on quality standards and utilization metrics.
- We’ve built templates and questionnaires providers can use to communicate specific clinical information we need to expedite the clinical review process.
- We regularly evaluate the effectiveness of our prior authorization processes and if we find that any of them aren’t effective, we make changes, such as removing certain services from requiring prior authorization.
6. Do you coordinate your activities with any other Blue Cross programs, such as the Physician Group Incentive Program or Blue Cross® Coordinated Care?
We work closely with Blue Cross Coordinated Care, our new care management program. Our prior authorization processes allow us to be proactive in referring a patient to the program. For example, if we get a prior authorization request for a member with chronic conditions who would benefit from care management, we can refer them to the program at that time. That way, the member can begin receiving care management services before Blue Cross receives a claim for services.
7. What challenges do you face in implementing prior authorization?
Our biggest challenge is that providers don’t always utilize the electronic tools we have available. For example, we have electronic portals for all our prior authorization programs, and when providers don’t use them, they need to call or fax their prior authorization requests. This can result in significant delays. We’d like more providers to use the technology that’s available so we can make the process more efficient.
8. What should providers do if they need additional information on available technology?
We have a range of resources and training, including webinars and tutorials. They can contact their provider consultant for more details.
9. Has the COVID-19 pandemic changed how you handle prior authorization requests?
Yes, the pandemic has affected nearly every area of our business, including prior authorization. For example, as we communicated in a May Record article, we waived clinical review authorization requirements for our medical acute inpatient hospitalizations and for the first three days of a skilled nursing facility admission.
10. What is your vision of what utilization management will — or should — look like in the future?
If certain standards of care were practiced consistently, it would limit the number of services that require utilization management procedures. (Dr. S. George Kipa, our deputy chief medical officer, wrote extensively on the issue of variation in clinical care in a column in the previous issue of Hospital and Physician Update.) And for those procedures that do require review, we’d use technology to automate real-time decisions. But until we get to that point, we’re collaborating with our providers to make sure our members receive affordable, quality, timely health care.
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