Blue Cross continues efforts to streamline prior authorization process

Blue Cross Blue Shield of Michigan is continuing to refine its prior authorization programs, relaxing about 20% of prior authorization requirements.

This move is part of our ongoing efforts to reduce administrative tasks for clinicians, while improving health care quality, access and affordability for our members.

Prior authorization is necessary to help ensure medical necessity and the appropriateness of services and prescriptions. Blue Cross’ prior authorization program promotes patient safety for members and provides assurance that the member gets effective care at the appropriate time.

“We are focused on partnering with the physician community to ensure that our members are getting timely care they need without roadblocks,” said James D. Grant, M.D., senior vice president and chief medical officer at Blue Cross Blue Shield of Michigan. “We are developing front-line clinician-led pathways and systems to ensure the highest levels of safety and quality.”

Blue Cross is known in Michigan's clinical community for streamlining its prior authorization process through technology and an extensive “gold carding” program. “Gold carding” streamlines prior authorization for physicians who have a proven track record of making appropriate evidence-based decisions by exempting them from third-party prior authorization approval processes.

Improvements

To accelerate access to the highest quality care without undue delay, Blue Cross will be expanding its gold carding program. “Our goal is to partner with clinicians to improve the prior authorization process so they can spend more time taking care of people and less time taking care of paperwork,” Dr. Grant said. “As a physician, I know first-hand what physicians and their teams experience every day. We seek to minimize the amount of time physicians, nurses and their staff spend on paperwork, the computer and the phone.”

After thorough analysis, Blue Cross eliminated hundreds of medical procedures that previously required prior authorization review. That gives practitioners additional time to provide care for our members.

The role of technology

Technology has helped to accelerate the prior authorization process at Blue Cross, with a significant majority of requests submitted electronically.

“Blue Cross processes roughly 87 million claims each year, and about 2.5 million, or roughly 2%, go through the review system,” said Jeniene Edwards, R.N., vice president of Utilization Management at Blue Cross Blue Shield of Michigan. “Most prior authorization requests are submitted electronically and approved within seconds using automation that expedites the process. Our goal is to leverage multiple channels of technology for transparency and automation, which also enables us to accelerate decisions to minimize disruption to our members.”

As technology platforms continue to evolve, Blue Cross’ ultimate goal is to move away from the concept of “authorization.”

“Our long-term aim is to let these advances enable us to move from a world of ‘authorization’ to ‘clinical decision support,’” Dr. Grant said. “This way, all stakeholders, especially physicians, nurses, their staff and our members, will be able to quickly receive transparent, evidence-based decisions and status updates through their electronic medical record. This also ensures that coordinated care moves forward safely and without delay.”

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.