Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep178: A year after the prior authorization pledge, what changed? with Colin Banas, M.D., of DrFirst
Transcript
- Colin Banas, M.D., M.H.A. 0:00 If you digitize it all and the process is still broken, then it was the process was the problem all along. Austin Littrell 0:10 Welcome to Off the Chart, a business of medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Physicians Practice Managing Editor Keith Reynolds sat down with Dr. Colin Bannis, Chief Medical Officer of Dr. First, and the former Chief Medical Information Officer at VCU Health System. In June of 2025, dozens of health insurers pledged six fixes to prior authorization. Dr. Banis was skeptical then, and a year later he says he feels vindicated. Today, Keith and Dr. Banis go through the pledge, commitment by commitment. They get into why prior authorization has overtaken the electronic health record as physician's leading administrative complaint, and they look ahead to January 1st, 2027, when the federal interoperability rule stops asking Paris to cooperate and starts requiring it. Dr. Bannis also lays out two things that a practice can do this month to get ready. With all that said, Dr. Bannis, thank you for joining us. Let's get into the episode. Keith A. Reynolds 1:14 Hey there, folks. Today we're talking to Dr. Colin Bannis, Chief Medical Officer of Dr. First. How you doing today, Colin? Colin Banas, M.D., M.H.A. 1:20 Good, good. Thanks for having me. Keith A. Reynolds 1:22 Oh, it's our absolute pleasure. So let's dig right in. A year ago, you were skeptical that a voluntary pledge from insurers would fix prior authorizations. Were you right? Colin Banas, M.D., M.H.A. 1:32 I mean, I hate to say I told you so, but I feel like I I feel a little bit vindicated. Let's just say that. So yes, I was, I was very dubious back in I think it was June or May of 2025 when this group, this coalition of insurers, got together and said, "Hey, we're going to make a prior authorization better, and here's like six things that we're going to do, and it felt very much like a rerun of prior pinky pinky swears and Pinky promises. The most recent was back in 2018, almost the same same kind of pledge. And I guess the reason I feel a little bit vindicated is I'm a big I'm a big cinema cinephile, so I love movies. And you know, there was a movie and a comic book many years ago called the Watchmen, and the the tagline for the Watchmen was, "Who's watching the Watchmen? And so when I think about the pinky swear that we're going to talk about here, a lot of the you know results are coming from the people who are making the Pinky swear themselves. There's no external validation. If anything, the external validation would come in the form of what my peers are seeing on the front lines. Keith A. Reynolds 2:50 Yes, it's very much one of those we investigated ourselves and found we've done nothing wrong sort of deals. Colin Banas, M.D., M.H.A. 2:55 Exactly, exactly. Keith A. Reynolds 2:56 So let's you know let's back up to to last year. You know what did the insurers actually promise, and you know, of that, what have they actually delivered? Colin Banas, M.D., M.H.A. 3:05 Yeah, so I I needed to check my notes on this too. So indulge me, but there was basically six six pillars of of the pinky swear. The first was, hey guys, when you submit an appeal, we're going to have somebody who's qualified in your specialty actually doing the review on that because a lot of the complaints were, you know, the person who's looking at my you know request for a very specific kind of breast surgery has no idea what breast surgery involves and you know who qualifies for these complex procedures, so that was one. The two was going to be reduce the scope of claims that were subject to the PA. So that was kind of probably the biggest part of that was, hey, we're going to reduce. I think one of the insurance companies said we're going to reduce prior authorizations by 20% or maybe even 30% We're going to the third one was if you've been previously approved for a prior authorization, we're going to honor it for 90 more days if the plan switches. Okay, the fourth was you know again not very not very high on specifics, but if it is denied, we're going to give you very clear language as to why this was denied. The fifth was standardize the electronic PA using the Fire APIs, which is which is good, right? That is also something that was already in motion by mandate, which I'm sure we'll get into. And then the last one was 80% of electronic PAs will, if they're approved, they'll be approved in real time. So I'll pause there for the for the six pillars to see if there's any questions, and then we probably can go line by line as to which ones are actually in effect or actually have measurable results. Well, Keith A. Reynolds 4:57 yeah, it will hit me with it. I want to know. Let's what? What did they actually do? Colin Banas, M.D., M.H.A. 5:02 Yeah. So, and this is you know this is what we led with at the beginning is that a lot of the data that that I was able to dig up is self-reported, or if I'm looking for the sentiment from my frontline colleagues, you could have to you'll go to things like AMA surveys, annual surveys, or AHA surveys to figure out what what my my peers are are seeing. So for the very first one that said you know qualified someone in my specialty is going to be reviewing this appeal, the survey said that only 24% of providers were actually seeing that in practice. So three out of every four docs are saying, "Hey, that still isn't happening. The second pillar reduced the scope of claims subject to PA. All we have is folks like you know Blue Cross Blue Shield saying, "Hey, from last year we've reduced PAs by 11%. But I don't know that. In fact, if anything, if I ask my colleagues, they think the number of PAs is still going up, the amount of time spent on PAs is going up, and the denials, if anything, are going up. So, again, you know that's their data saying, "Hey, we cut it. Don't know. Honor existing PAs when switching plans. I I haven't. I couldn't find anything. I don't know if that's really happening. It's that's almost something I'd have to not only ask my provider colleagues, but also the patients out there. Like, hey guys, what are you seeing when your biologic flips plans at the beginning of the new year? My guess is that it's not being honored, and they're still jumping through a lot of hoops. And the real problem with all this, of course, which I'm sure the listeners know, is like not only is this how providers get frustrated and burnt out, but this is how patients get hurt. And I actually have some real world stories about personal friends going through this process who ended up legitimately getting hurt. Okay, clear, plain language denial explanations. I don't know. You know, gonna have to find some independent auditor to figure that out. That's not really one of the big ones. So standardized electronic PA. So this is for a health IT company in medication management like Doctor First. This is the big one, right? This is the one that actually lays the pipes for some of the other metrics, and the ability to measure this stuff is when we start the process flowing through fire-based APIs. They, you know, there's a few out there. I not very many now. The mandate doesn't require them for medical medical claim based until the end of this year. That's like five months away, or maybe it's maybe it's February, but whatever it is, they've got five months to hit that. The one for prescriptions, which is what I really am looking forward to, actually doesn't kick in until January one of 2027. Colin Banas, M.D., M.H.A. 8:03 The Colin Banas, M.D., M.H.A. 8:03 mandate that doesn't mean they can't be doing this ahead of time, and a very few number are. But to make a pinky swear saying, "Hey, we're going to do this, when in the background you're being forced to do this, at least in the CMS payer community, I don't know. It feels a little disingenuous. It feels like taking credit for something that you were going to have to do anyway, and then 80% of electronic approvals in real time. I haven't seen any measurements on that. I certainly know that when I'm prescribing, I am not seeing that in the slightest. So I'm not here to beat up on the PBM and payer community, but let's just say I do feel as we led with a little bit vindicated about the efficacy of a pinky swearer. Keith A. Reynolds 8:50 All right, so let's get into that sort of frontline feedback. You know, you're talking to physicians every week. What are they telling you about how the process feels today compared to a year ago? Colin Banas, M.D., M.H.A. 9:00 It's as bad as ever. I mean, again, I hate to be negative, Nancy, on this stuff, but you know, look at any metric about the things that the physicians are complaining about. The PA friction is actually overtaking the EHR friction. You know, like EHRs are almost no longer the number one bad guy, which is, you know, I think they were an easy target, and we can. There's a variety of reasons why EHRs were were getting a lot of bad press, but you know, with the advent of AI and some of the tools that are reducing the burden of interacting with the the screen and and refocusing on the patient, you're seeing like a an even more a bigger swing towards taking aim at the at the PA process at the friction created by that, and they're most likely to cite that as one of the causes of burnout. Yeah, I I don't think. In a meaningful way, they're they're seeing anything different from June of 2025. I think some some very progressive health IT companies who have been fortunate to work with very progressive segments of the para community have chipped away at specific use cases, and the the easiest one that comes to mind is some of the success we've had and others have had in the GLP one prescribing experience. We've been able to do very dedicated things that have led to in real time almost avoiding the PA altogether because you were able to satisfy a whole bunch of things in the background in you know nanoseconds, but that's not that's not scaled. That's not extensible to the entirety of the PA process. So I still I still see frustration. I still see you know rooms with fax machines, which is you know unbelievable, and dedicated clinical teams with multiple browsers open because they're interacting with different portals for different payers and different drugs, and so it's all very much spaghetti. It's all very much a non-unified experience, and it's it's wasteful. All Keith A. Reynolds 11:24 right, so let's let's back up to you know what's mandated. You know, like you mentioned, January 2027 is less than six months out. What's got to be built by then, and you know who's behind schedule? Colin Banas, M.D., M.H.A. 11:35 So this is the this is the one I was referring to about the men. the med, your medical benefit prior authorization. So think of scans or surgeries, procedures or infusions. Now, granted, some medication therapy is obviously on your medical benefit. A lot of those biologic infusions are on there, but the thing that I'm more focused on is the one that's a year from now, which is around like full prescription benefit automation or at least digitization. So for for in the next six months, they need to build basically from electronic electronic standpoint four different APIs that all of the players in the ecosystem should have access to. So, if you remember, it'll be things like provider to payer API, meaning I need a way to go get that question set and understand the rules of this PA and submit. There is a payer to payer API, meaning you know I switch from payer A to payer B. Payer B needs to understand, you know, the legacy of your prescriptions and the approvals. Like, let's make that easier. There's a patient to provide to payer API, which is, hey, insurance company, what do you got on me? Like, or let me interact with the rules of the game so that from a patient perspective, I can be more informed, and then oh, what is the fourth one? It it's almost folded into the provider to payer one, which is the PA itself. So, so not only am I interacting with the provide with the payer community to get data on what you have for my patient, because you might have additional data that I don't have, but I also need to be able to do those those fire endpoints for the full PA. Keith A. Reynolds 13:32 Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven real world tactics you can plug into your practice today, whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom; they come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at kreynolds@mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute. Okay, so you know, walk me through you know what a prior authorization is supposed to look like once all these APIs are are live. Yeah, what changes for the patient at the at the pharmacy counter? You know, Colin Banas, M.D., M.H.A. 14:37 it's I I tell you what, and I'm sure you've experienced this as well. Is there's a alarming number of times the patient shows up to the pharmacy counter only to find out that the PA is required and that a message has been sent back to your doctor to initiate the process, and that's called a retrospective PA, which is. It's almost insanity to me. Like you know, we can't figure this stuff out in the year 2026 with all of the you know the strides we've made in health technology. So, I guess if I had to pick one word for what it looks like, it fully transparent. Like that's what I want the process to be. That's what the patient deserves the process to be. So the provider knows at the moment if there's going to be additional steps on their end, or the provider knows that they've avoided the PA because the the system took care of it in the background. Many of my colleagues and I share the same motto: like the best PA is the one I never had to do, right? And so that's that's sort of what I want to get to is let's limit PAs to when they really do need to be reviewed, and there really is clinical evidence for why this might not be the appropriate next step. Because right now, like 80% plus of all PAs that are appealed are reversed. So that's insane, right? That's that's almost like a business. It's like it's like a way of doing business, you know, to make the money on the arbitrage of having that delay, rather than if you know if you're going to eventually allow for 80% of the things that you initially denied. That just seems it doesn't make a lot of sense to me, especially when patient outcomes are at stake. So, if I had to pick one word, it would be transparency for all involved. You know, just like on your on your app, you can see where your pizza status is. I want to see that. I want the patients and the providers to have that as well, and that's what this framework will eventually lead us to, hopefully. Keith A. Reynolds 16:46 That's where we're all dreaming for healthcare to reach the point that dominoes hit 10 years ago. Colin Banas, M.D., M.H.A. 16:52 Isn't it crazy? It's all Keith A. Reynolds 16:56 right. So, where do you think this deadline breaks down? You know, what's the most likely failure point? Colin Banas, M.D., M.H.A. 17:02 It's probably if I had to guess, it would be on the payer or maybe even the vendor side. Is like, are you guys going to be compliant by these deadlines? I know at Doctor First, we're fully prepared already to be participating in these these new fire based APIs and piping, but if we don't have somebody to connect to on the payer side, it's sort of all for naught, and it's going to break down back to the current process, which is a lot of phone calls and faxes. The other thing would be as a as a subset of that is enforcement. Like, okay, so you weren't compliant by the the the dedicated time. What happens? Like, you know, how do we shame you publicly, or how do we hit you from a certification standpoint or financially? Like, what's going to happen? Because you saw this play out until recently in information blocking, which was there were real examples of information blocking that were getting reported and getting investigated, and nothing was happening. Like there was no, you know, now there's actually a little monetary punch, but for you know at least two two plus years of the initial info blocking rule. Nothing was really happening to the bad guys, so I hope we don't make that same mistake here. Because what's what's so great about what's happening now is that this intense focus and light is being shed on this problem that we're finally going to get somewhere with it. Hopefully. Keith A. Reynolds 18:41 Well, let me let me ask you this. You know, if say that the you know the heavens open up and all this technology gets implemented and built, but these you know prior auth delays are still in place. You know, what does that tell us about you know the problem in general? Colin Banas, M.D., M.H.A. 18:59 That the incentives are perverse. That the that all of this friction really was by design, which I really don't want that to be true. But it it tells us that we've got to relook at how this whole thing is being incentivized. If you if you if you digitize it all and the process is still broken, then it was the process was the problem all along. I'll just leave it at that. Speaker 3 19:32 Right. Keith A. Reynolds 19:33 So you know we've talked about what's wrong, what hasn't gotten better, our dreams for the future. But let's take a step back. You know, is there anything that has genuinely gotten better over the past year? You know, let's let's give a little bit of credit where it's due. Colin Banas, M.D., M.H.A. 19:48 Yeah, I I will. So I think because of that intense focus, and that's the frustration not only from the provider side, but also the patients are getting involved now too. You're you're seeing like activated patients. Making a lot of noise in social media or with their local legislation, saying like, "This is not right. Like, this needs to be addressed. And I think with that focus and that pressure comes things like the progress. You know, like I told you, there are some edge cases that are already opening up that are actually you know very very successful. There are some payers who have promoted their gold card program. So gold carding is if a doctor submits, you know, 10 PAs for this infusion, and they're always approved because his doctor knows what he's doing and has already followed the evidence, etc. Then let's stop having him do PAs because that guy he clearly knows what he you know he's he's doing it right. So it's sort of a way of like you've earned our trust, therefore we're going to stop the friction. And I've seen some progress in those. And then the other thing is, you know, with the advent of AI and LLMs, you're seeing a lot of things that have lent themselves to automation start to trickle in, and I think PA is one of those use cases that really does lend itself to. Okay, we might not be able to get 100% of the PA done via automation, but we can get 80, and if I can, you know, take 80% of the work off of your plate through, you know, a doctor first solution or an AI solution, and leave the 20% to something that really clinically needs, you know, extra set of eyes, that's actually still meaningful progress. And so those are the things that I'm very excited for, and I think this is all because of, again, that intense focus and scrutiny that that this whole process has been finally put under the light. Keith A. Reynolds 21:48 All right. So, last question for you: We here at Physicians Practice, we our bread and butter is you know practical tips that you know practice managers can use. We use practical and practice a lot. I've noticed in the, especially in that last sentence there. So, what's thing? What's one thing a practice manager can do this month to be ready for 2027? Colin Banas, M.D., M.H.A. 22:10 I would definitely check in with your EHR or your prescriber vendor and figure out where they are in terms of compliance, expected compliance, because there's not only is this coming up, but there's other really important things like NCPDP standards that are like right, right afterwards, and so you really need to be on top of them to make sure that they are indeed going to be compliant. The other thing is selfishly, I kind of want them to track currently, and maybe they do. What are you seeing in terms of approvals, denials, and then you know subsequent reversals, so that we can actually have this baseline for when we finally lay the the tracks? To know back to your earlier question, did we actually make a difference by digitizing this, so I almost want the before so that I can test the after, and that's just from a selfish perspective. But I think it would behoove them too, because you can't manage what you can't measure. So measurement is key. Keith A. Reynolds 23:15 Alrighty, so Colin, that's all I got for you today. Is there anything else you want to add? Anything you think I'm overlooking? Colin Banas, M.D., M.H.A. 23:21 No, look. Let you know, let's do it again in six months and see see if see if any of my predictions came true. But I do want to end on a positive note, and I do think we're starting to chip away, and I think that's a good thing. Keith A. Reynolds 23:36 Definitely. All right, Colin. It's been an absolute pleasure. Thank you so much for joining us today. Colin Banas, M.D., M.H.A. 23:42 Oh, thank you so much for having me. Anytime. Austin Littrell 24:01 Once again, that was a conversation between Physicians Practice Managing Editor Keith Reynolds and Dr. Colin Bannis, Chief Medical Officer of Doctor First. My name is Austin Latrell, and on behalf of the whole Medical Economics and Physicians Practice teams, I'd like to thank you for listening to the show and ask that you subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. You can find us by searching "Off the Chart" wherever you get your podcasts. And if you'd like the best stories that Medical Economics and Physicians Practice publish, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart, a business and medicine podcast is executive produced by Chris Maslini and Keith Reynolds, and produced by Austin Latrell. Medical economics and physicians practice are both members of the MJH Life Sciences family. Thank you.