Blue Cross Blue Shield of Michigan eases prior authorization requirements

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Blue Cross Blue Shield of Michigan has said that in an effort to expand access and affordability for members, it's further reforming its process to relax approximately 20% of prior authorization requirements.

The move would also reduce administrative tasks for clinicians, the insurer said.

BCBSM defended prior authorization as important to validate medical necessity and the appropriateness of services and prescriptions. 

"We are focused on partnering with the physician community to ensure that our members are getting timely care they need without roadblocks," said Dr. James D. Grant, BCBSM's senior vice president and chief medical officer. "We are developing front line clinician-led pathways and systems to ensure the highest levels of safety and quality."

WHAT'S THE IMPACT?

As part of this move, BCBSM will be expanding its "gold carding" program. "Gold carding," the company said, 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.

The goal, said Grant, is to partner with clinicians to improve the prior authorization process so they can eliminate some of the time they spend mired in paperwork. He cited an analysis showing the organization has eliminated hundreds of medical procedures that previously required prior authorization review.

BCBSM said it processes roughly 87 million claims each year, and about 2.5 million, or roughly 2%, go through the review system. Most prior authorization requests are submitted electronically and approved within seconds using automation that expedites the process.

"As technology platforms continue to evolve, our long-term aim is to let these advances enable us to move from a world of 'authorization' to 'clinical decision support,'" said Grant. "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."

THE LARGER TREND

The action from BCBSM follows similar moves by other insurers, including Cigna Healthcare, the health benefits provider of the Cigna Group, which last month said it will be removing close to 25% of medical services from prior authorization requirements.

With the removal of these 600-plus additional codes, the company has now removed prior authorization on more than 1,100 medical services since 2020. Cigna said the goal is to simplify the healthcare experience both for consumers and for clinicians.

An American Medical Association survey released in March found that 94% of physicians report delays in care associated with prior authorization. Physicians spend almost two business days each week on prior authorization requests, and 35% of them have had to hire additional staff to handle the administrative burden exclusively, the AMA said.

Other survey results show 80% of physicians report that prior authorization can at least sometimes lead to treatment abandonment. Meanwhile, 33% report prior authorization leading to a serious adverse event for a patient in their care – with 9% reporting it's led to permanent bodily damage, disability or death.
 

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com