Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep61: Prior authorization with Heather Bassett, MD
Transcript
- Speaker 1 00:00:00 If you want to get a physician riled up, just start talking about prior authorizations. Speaker 2 00:00:09 Welcome to Off the Chart: A Business of Medicine podcast featuring lively and informative conversations with health care experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. I'm your host, Austin Littrell. This episode features a conversation between Medical Economics managing editor Todd Shryock and Dr. Heather Bassett, Chief Medical Officer of Xsolis. Dr. Bassett joins the show to talk prior authorizations and how technology could change the game. Speaker 3 00:00:40 I'm here with Dr. Heather Bassett, Chief Medical Officer of Xsolis, to talk about the prior authorization process and how technology might be able to help. Doc, thanks for joining me. Speaker 1 00:00:51 Oh, well, thank you for having me. I'm excited for this conversation today because it's definitely top of mind of a lot of physicians. Speaker 3 00:00:59 So from a physician's perspective, what are the biggest pain points today in the prior authorization process? Speaker 1 00:01:07 Yeah, so I think I'm a data person. So I think like just hearing some of the numbers really puts into context the pain points that physicians have. Speaker 1 00:01:17 So if you think about, Medicare, approximately like 60 to 70 million, you know, members are enrolled in either Ma plans or traditional Medicare. and roughly half of that is actually med advantage plans. And it's growing every year as we have a, you know, increase in our aging population. what what you end up seeing in the Ma plans is approximately 50 million prior authorizations in 2023. That relates to roughly two authorizations per enrollee. If you look at traditional Medicare because they don't require prior office on nearly as many, Procedures, medications, hospital stays, skilled nursing facilities. it's 400,000 authorizations in 2023, and it's one authorization per 100 employees. So there really is this imbalance in Medicare Advantage and just a tremendous volume of, prior authorizations. And it's a huge pain point for physicians. It's a very manual process. If you talk to them. A lot of these are done over the phone. so that is very time consuming. they're also they don't always know what the rules are. And it depends on which, you know, insurer that you're working with. Speaker 1 00:02:39 you know, how they, you know, what their requirements are, what they are kind of grading you on as to whether you it is authorized or not. it's also hard to explain to patients. So patients, you know, you then have been these conversations with patients and they don't understand why they couldn't get the medication you ordered or they, you know, they get a bigger bill than they were expecting. so I think those are just some of the many pain points. If you want to get a physician riled up, just start talking about prior authorizations. Speaker 3 00:03:11 So how is technology currently being used to streamline or automate the prior auth process? Speaker 1 00:03:18 Yeah, it's a bit of a hodgepodge right now. And that that is because, there's there's really no consistency, or standardization out there. again, if you're working with, you know, each of the advantage plans, you know, for example, the blues, each blues is, is a very it's kind of their own entity and they have their own way that they do things. Speaker 1 00:03:44 so even within Ma plans, there's a lot of inconsistencies. so it's very hard to put technology layers in place to help. And again, I'd mentioned, like, you know, you're on a phone a lot of times faxing things to to payers. That being said, you know, there has been a push to improve the process. CMS has gotten involved, as well, put a lot of requirements in place, around interop and prior off, they had a final ruling that came out in 2024, in 2026. you know, plans are having to be more transparent. and and they're having to in 2027, be compliant with APIs. And the way, that way that, data is, is processed between payers and providers and providing payers so that that work has started to move in that direction. I mean, what's pretty heavily used, our rpas or robotic process automation, which is able to help with simple, tasks. Simple repetitive tasks. You see a fair amount of of that. you're starting to see some kind of pipeline. Speaker 1 00:05:01 Data pipelines between payers and providers being built like ability is is one of the companies out there that's doing a lot of work to to bridge data sharing. payers themselves are creating portals. So you're logging into portals instead of getting on a phone or faxing, information. so starting to see that, that, pieces of automation come in, but again, very difficult right now because of, you know, every, every payer does it a little bit different. hospitals have different EMR. So, so that inconsistency just makes it challenging. Speaker 3 00:05:42 AI is everywhere now. It seems like every day you're reading about a new AI device or technology can can I step in here and help reduce these administrative burdens and make this process better? Speaker 1 00:05:56 Yeah, I think I really is our best opportunity to start to move the needle in this space. because you mentioned, like, rpas. you know, they're they're they're very good at repetitive tasks or even as some natural language processing that that's helping to scrape information. but it can only take you so far. Speaker 1 00:06:19 The advantages of, of artificial intelligence is you not only have your predictive machine learning models that can help, you know, you know, help you understand if a case is likely to be approved or not. but you're starting now to see generative AI. Everyone's kind of heard of ChatGPT. that that is kind of taking things to the next, level of being able to summarize clinical, information. we as a, as a company, have been pretty intentional around artificial intelligence, Because again, we, you know, we've we've been using it for a little over ten years now to help provide efficiencies for our, our clients. And we're one of the few vendors that has actually decided to sit between the payer and the provider. and I has kind of been that neutral space that has allowed us to drive efficiency. So using machine learning to identify cases that can be identified as being able to automatically approved, and so it is we're we've started to see it, but I really think we're kind of at the precipice of jumping off and seeing, quite a bit of, of automation in this space which ultimately will benefit not only, you know, physicians, but, but, you know, really talking about the patient and better outcomes for the patient. Speaker 1 00:07:53 and, and kind of getting them more transparency and less healthcare is confusing for a patient, and how do we make it less confusing for them? Speaker 3 00:08:04 We've seen stories of insurance companies issuing mask denials using technology. You know, is that a risk of relying too much on automation? And are we going to get to a point where it's just the payers use of AI? Is canceling out the physician use of AI in prior authorizations? Speaker 1 00:08:22 Yeah, I think part of the prior authorization process is, you know, cases get claims get denied. And then, you know, the, the physician, the hospital has the opportunity to appeal that. and one area where we're seeing generative AI is creating appeal letters, because it's very good at summarizing clinical information. So you kind of wonder if, if the, you know, the physician or the hospital is creating a, you know, using generative AI to create an appeal letter, and then the rebuttal coming from the payer is, you know, are we going to enter into the battle of the bots and those types of scenarios. Speaker 1 00:09:00 I don't know. but but if you if you kind of take a step back because I mentioned, you know, there's tremendous volume of, of, I think it was like 50 million, prior authorizations in 2023. of those, or if you speak to, physicians, you know, an average physician does 39 prior authorizations a week, and it takes roughly 13 hours for the between the physician and their staff to take care of those authorizations. If you, of authorizations, roughly 7 to 10% are denied. so that does mean 90% are approved, very manual to get those 90% approved. So if you're able to use AI to, you know, kind of tackle that portion there in and of itself, regardless of if there are some, you know, slight increases in denials or other kind of things people are worried about, you're going to see tremendous benefit from a from a physician, from a hospital standpoint, in automating the large number of prior authorizations that are approved. Speaker 4 00:10:19 Say, Keith, this is all well and good, but what if someone is looking for more clinical information? Oh. Speaker 5 00:10:25 Then they want to check out our sister site, Patient Care Online. Com the leading clinical resource for primary care physicians. Again that's patient care online. Com. Speaker 3 00:10:39 Do these technologies need to integrate directly with the HR and the insurance systems. And what's the biggest challenges to doing so. Speaker 1 00:10:50 Yeah the short answer is yes. we've got to get away from from phones from I mean, we're in 2025 and still talking about fax machines, which is crazy. I'm sure you remember I still have the voice. You know that sound of a modem and a fax machine? You know, machine ingrained in my, in my brain? but, you know, the EHRs are where physicians work. and it's also where the data lives. So regardless of whether you're fully integrated into an EHR from a, you know, from a vendor standpoint or, you know, through the EHR itself, or whether you're more of a bolt on or just getting data that's applied elsewhere, you need need to be integrated to get real time clinical data. Speaker 1 00:11:40 Because if you don't have real time clinical data and being able to make proactive decisions, you're not going to be effective in this space. The other thing you mentioned, the payer piece. So, you know, obviously providers don't work in a bubble. there's that integration with the payor and the back and forth and sharing of information. and so you also need that integration on the payer side. And fortunately, work is being done in that area. I think it's going to take us a little longer than we would like for that to happen. And again, part of the problem is, on the payer side, there's a lot of old tech out there. And in order to get to the more modern ways of of exchanging information, and taking advantage of standard, fire APIs, which is kind of what is the, you know, really, leading the charge and, interop and standardization, like, there's a fair amount of work that's going to happen, have to happen in a short period of time to get ready to be able to to, you know, have that type of data exchange and, and layer these efficiencies. Speaker 3 00:12:56 How much time do you think an automated prior auth process could save physicians? And are there any new challenges that might come up? You know, there's always the law of unintended consequences. You know, are there any new things that might come up that physicians would have to deal with as a result of an automated process? Speaker 1 00:13:15 Yeah, I think, you know, I think there's a, you know, there's some numbers out there that say you could say save 70 to 80% of, time that physicians spend on prior authorization. So there's an opportunity for a big win. and, you know, I was I mean, it's part of the reason I ended up working, for excellence is I was really starting to lose the joy of practice. is there so many administrative layers, whether it be prior auth or other things that physicians end up having to do that takes them further away from the the patient. So being able to decrease, you know, administrative waste, whether that be prior auth or other tasks that physicians have to do, and get them back to the, you know, in front of the patient. Speaker 1 00:14:06 And, you know, the whole reason that we went to med school to take care of the patient. I mean, that's that's a huge win. That but the counter to that you mentioned, are there any new, challenges? The counter is, adoption of new technologies. It's hard. you know, physicians, we can be a little stubborn, at times. you've you kind of develop what you consider a very good process to be as efficient as possible and getting, you know, it's that change management piece, and getting them to use because sometimes you're a little bit less efficient before you're more efficient with new technology. So there's that utilization piece. Another big piece that we're seeing around artificial intelligence is trust. Like how can I trust that this is going to do what you say it's going to do, that it's not going to create more work for me because of errors. so there's that that trust piece. And I'm a big proponent of responsible, I, it's part of the reason we joined, chai the, Coalition of Health Care Alliance, this year is, that in order to get that trust, to make sure you have best practices in place, so that, you know, we actually are able to do what we want to do, you have to be, you know, considered a responsible a, which is responsible AI, which is weighing rewards versus risks. Speaker 1 00:15:37 When you think about innovation, it also creates an environment that allows the physician to gain trust or whoever the end user is by understanding these processes or being put in place. So those are some of the things I think that'll be, challenges. And what we need to consider as, this technology is, is rolled out in the future. Speaker 3 00:15:59 Does this technology help reduce the number of inappropriate denials, or is it making appeals more complicated? Speaker 1 00:16:05 Yeah, that's that's an interesting question. I do think it is, decreasing the number of, of denials. and it's one, you know, kind of metric that, that we, look at as a company is how do you put processes on the front end to prevent denials on the back end? Because some of them are some denials happen. you know, because you inappropriately tried to authorize an inpatient when the patient really never met that that benchmark. sometimes it has to do with missing clinical information. sometimes, you know, it timing plays a role in it, or you're not, you're not holistically looking at the patient and making decisions. Speaker 1 00:16:54 so a lot of what, what we do is actually centered around appropriately getting the patient in the correct status and preventing denial. So there are a lot of use cases out there where artificial intelligence is being used. Machine learning, predictive models being used that do help prevent, denials. and then, you know, on the, you know, the second part of that was around, you know, does it make appeals more complicated? I, I don't know that it makes appeals more complicated. I don't I think we're still going to have denials. Like, I think, denial sometimes is seen as a as a four letter word, sometimes by, hospitals and, by physicians. In the current environment, denials are part of the process. And you have to be willing to accept that a denial is going to happen and put processes in the back end to address it and not be afraid to address it, because 80% of denials are overturned, which in and of itself, you know, speaks to the broken process. Speaker 1 00:18:09 so I don't think it's making them I don't think it's going to make them more challenging on the back end. I think we just have to be, you know, while we're helping on the front end with prior auth, you know, no, that denials are going to happen and put it's another opportunity for AI to play a role in the appeal process and help streamline that. Speaker 5 00:18:33 Oh, you say you're a practice leader or administrator. We've got just the thing. Our sister site, Physicians Practice. Com your one stop shop for all the expert tips and tricks that will get your practice really humming again. That's physician's practice. Speaker 3 00:18:50 Yeah, the AI has completely exploded. It seems like it went from this, like, oh, here's this new novelty technology, and now it's ingrained in everything, you know. What do you think prior authorization will look like 5 to 10 years from now? Speaker 1 00:19:06 Yeah, I think that's a great question. And I can, you know, I definitely can geek out on the AI space. Speaker 1 00:19:13 I mean, I think I'm, you know, one of the last generations of physicians that learned the way I learned, and, you know, treat patients the way I think things are just inherently going to change over the next couple of years. and I think, you know, I'm very interested to see how it plays out. I'm a little jealous, I'll be honest. I, I think it's tricky in the five year space. I am, you know, concerned about some of the, the changes that the new administration is putting in in place because and my concern is, is that, what's going to happen is, is more, There's going to be a shift. And unfortunately, I think I feel like health care may end up being, more pressure put on in the health care space. And when you start to put pressure on the health care space, Covid is kind of an example of that. You put pressure on the health care space. That innovation piece kind of tends to be moved a little bit to the side. Speaker 1 00:20:19 and so I'm a little concerned about that. I guess, you know, we will see how that, that plays out if you put that to the, the side. We have actually seen a lot of investment in innovation by, health care organizations out there, more so than we've seen in years. And it's because they recognize the innovation, particularly artificial intelligence, is how we're going to fix problems like prior authorization. We're going to fix, problems around clinician burnout, like physicians are leaving the workforce. Nurses are leaving the, the workforce. And I mean, staffing challenges are, you know, are real and have the potential to decrease, you know, quality outcomes that, you know, we as patients, you know, expect from the health care system. I do see the, generative AI piece expanding. there's generative AI is very good at summarizing clinical information, which can help with, you know, crafting how the information you send to the payer to get the prior authorization, helping with appeal letters. Speaker 1 00:21:32 and then if you kind of go to the next step, we're hearing a lot about ambient AI, and it's really kind of in the environment. and passively taking information and then adding context to it. there's kind of a, there's a lot of, quite a few companies out there. I mean, you can take a phone into a, you know, your primary care can bring it in and record the entire conversation. It's not just recording it. It's taking that information, consolidating it into a note that the physician can review. And it's already saving physicians large amounts of time. Well, now, if you take that and you think about also a gentle AI where you are putting allowing it to do some tasks autonomously in order to, have a, get to a goal, I think if prior authorization. So now, like, I'm, you know, a primary care, doc, and I'm talking with my patient who's going to need this medication or this procedure. The the I can impart of the ambient conversation, not only record the information, but start to pull information to round out that prior authorization and even kick it off. Speaker 1 00:22:54 So it's it's I think once we start to take all of these new technologies and put them together, I think there's tremendous, opportunity. So I see, I see a path in the next 5 to 10 years to really eliminate a lot of, you know, what gets, again, as I mentioned at the beginning, you want to get a physician riled up, you know, talk to them about prior authorization. So hopefully maybe they'll be riled up about something else instead of prior authorizations. Speaker 3 00:23:27 Most doctors will tell you that the EHR rollout was a disaster because there weren't enough doctors involved in the development process. So what can physicians do to influence the development of these prior authorization technologies to make sure they better serve their needs and their patient needs? Speaker 1 00:23:45 Yeah, that's a great example. I was at an AI conference a couple of years ago, and, somebody from, Google, the health care arm mentioned that exact thing. And this is really when kind of ChatGPT hit the the stage in 2023. and basically it was a call to action to the physicians, in the, the room, you know, remember the the EHR? We did not have a voice. Speaker 1 00:24:11 It basically was a glorified, you know, billing tool. when it first rolled out. They're better now. but, it was kind of this reminder of, of, you know, this is our time to have input on what the next iteration, looks like. So I encourage, physicians, just, you know, we we do like to learn. so I think education is kind of the first piece, you know, really understand, you know, what I can do, what its limitations are, you know, some of the words that are that are used, you don't need to be a data scientist, but, I think education is is key. There are a lot of Organizations like the American Medical, the AMA, the American Medical Association that are working with Congress to ensure that there are processes in place to standardize and improve the prior. So get involved with those organizations. And then, you know, like we we work with our clients and, you know, kind of, you know, talk with the, the, our end users, whether they're physicians, whether they're nurses, case managers. Speaker 1 00:25:27 You know, be part of those, you know, if you hear, you know, that they're looking for physicians to be involved in projects or, you know, something's being be be willing to be part of that, because that's the only way, that your voice is going to be heard. and to be honest, you know, if if you are an AI, if you're an AI company or you're, you know, a healthcare system that is using your own resources to build something. You can build the greatest AI model since sliced bread. If you don't think about workflow, you don't think about how the end user uses is and what their day to day world is like. You're going to have an unsuccessful rollout, so it's kind of on on both sides. I think, you know, the those that are building and those that are going to be using really need to partner up and be part of the process. Speaker 3 00:26:23 Is there anything else that you would like to mention that you think physicians need to know that we haven't talked about? Speaker 1 00:26:31 I think it's I mean, yeah, I think the education piece is is key. Speaker 1 00:26:37 I think it's, recognition that, AI is not going away. you know, it's it's going to be I mean, it's already ingrained in our day to day life. I mean, you can't, you know, open up your phone without some piece of AI assisting your day to day life, it's going to become more integrated into to health care. So I think education is is a is key. but I think it's you I think well, I think I think the other thing to consider is there's a lot of fear out there. There's fear that it's going to take your job. It's not going to take it's not going to replace a physician. It is not going to replace a nurse. I think it's recognizing that there's the potential to make your life better by augmenting what you do. so I think when people kind of get past that fear factor, they're more willing to work with the technology. I also think there is, you know, you you can hear all these stories in the news and they tend to gravitate towards, you know, the extreme sometimes in the AI stories. Speaker 1 00:27:55 and you know, that people kind of get, scared. There are risks associated with AI. I think you need to recognize what the. Those are. but I also think you have to, you know, recognize that the benefits and that healthcare is not perfect. So mistakes are made through manual processes. and even if the AI is not perfect, in a lot of cases, it is better than the manual processes. And so it's, it's, being part of that conversation. and, you know, through transparency, and, you know, recognizing that, that it doesn't need to be perfect in order to provide benefits and move the needle forward. Speaker 3 00:28:49 Very good. Doctor, thanks for joining me today. Speaker 1 00:28:52 Oh, it's nice to meet you, Todd. Speaker 2 00:28:59 Again, that was a conversation between Medical Economics managing editor Todd Shryock and Dr. Heather Bassett, chief medical officer of Xsolis. My name is Austin Littrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show. Speaker 2 00:29:11 and ask that you please subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts so you don't miss the next episode. Also, if you like the best stories of medical economics and Physicians practice publish delivered straight to your email six days of the week. Subscribe to our newsletter at MedicalEconomics.com and PhysiciansPractice.Com. Oh, and be sure to check out Medical Economics Pulse, a quick hitting news podcast that offers concise updates on the most important developments affecting your practice, your bottom line, and the broader health care landscape delivered by the editorial team at Medical Economics. Off the chart, The Business of Medicine podcast is executive produced by Chris Mazzolini and produced by Keith Reynolds and Austin Littrell. Medical economics, Physicians Practice and Patient Care Online are all members of the MJH Life Sciences family. Thank you.