Health care providers have long expressed dissatisfaction with the time they spend coordinating care with health plans and getting paid. 

Indeed, one of the most inefficient and costly processes for providers and payers is the Prior Authorization procedure — so it’s no surprise that it was among the most talked-about topics during the America’s Health Insurance Plans AHIP Institute 2014 event in Seattle in mid-June. 

Prior Authorization is the process of obtaining approval from a payer for a patient to see a medical specialist.  This effort is burdensome, costly and inefficient, both for health care providers and health plans.  Without Prior Authorization, providers run the risk of serious disruption of their revenue cycle because health care claims can be denied. The Prior Authorization process and terms to describe it today are non-standard. New regulations emerge this year effective in 2016 aimed at addressing shortcomings.  The regulations are designed to standardize the Prior Authorization process, reward efficient payers and providers, and penalize those who are less efficient. 

[Related: Top 10 Government Health IT stories of 2014, so far.]

Health care consumers are also demanding mobile applications that allow them to instantly view their copay at the point of care, and pay for their health care services before they leave the doctor's office.  These services allow patients to pay at the time of service based on their health insurance benefits or cash price for those without insurance. Shifting to patient-centered, risk-based high-deductible health plans and mobile data at the point of care gives patients the opportunity to potentially receive a cash discount and avoid the surprise of additional bills later in the mail.

On the verge of disruption
Two new companies aiming to capitalize on this opportunity, with cloud analytics, rules engines, and mobile technologies, caught my eye. Those being Informatics In Context and Wellero.

According to Steve Sandy, co-founder of Boston-based Informatics In Context (IIC), the manual process for pre-authorizations is about to be disrupted. IIC claims to be the first solution that supports the PPACA operating rule to process pre-authorizations in true real-time using auto adjudication without requiring manual processes for the majority of the requests.

IIC describes itself as “a cloud-based clinical analytics company.” Its mission is to automate and streamline referral and Prior Authorization processes in real-time via an EDI 278 transaction between providers and payers. IIC claims to offer true real-time adjudication for Prior Authorizations by combining an eligibility check using the HIPAA EDI 270/271 transactions, then sending referrals and Prior Authorization using a EDI 278 transaction to a payer in the provider’s network, in a single transaction, without needing to login to individual payer sites. Before submission, IIC claims that Prior Authorization requests are reconciled against payer policy guidelines to ensure compliance.  Currently, IIC is in production with an eligibility solution and is beta testing its Prior Authorization solution. 

“The PPACA requires real-time processing of a 278 transaction but health plans will be left to determine if they can scale their business without a real-time adjudicated response rather than sending people to a call center,” Sandy said. 

Post-N-Track, a cloud based interoperability and EDI clearing house company, is partnering with IIC. As CORE Operating Rules phase in and require real-time data at the point of care, Post-N-Track believes solutions like IIC will be more important. 

“The Prior Authorization is often an ‘orphan’ transaction because providers send it and the payers then receive it and request manual follow up,” explained Post-N-Track senior director of business development David Barth.

Many health plans don’t have procedures for the 278 because it is simply too costly to scale cost effectively due to manual components of the process, according to Barth. As a result, payers outsource the workflow to call centers and others. 

Convergence ahead
Cambia launched mobile health company Wellero in 2013 which offers consumers a mobile application to pay for services before they leave the doctor's office. 

At AHIP, the company was marketing its product benefits to plans and providers, pointing out that users don't need to purchase new software or equipment to use Wellero. The patient's smartphone can access the system directly.  Wellero is part of a growing trend in the mHealth industry to target healthcare payments at the point of care — especially out-of-pocket (“patient responsibility”) charges, which usually account for over one-third of a patient's bill.

But storage is a constraint for many mobile devices. The cloud, on the other hand, has virtually limitless storage. The power of the cloud is merging with just-in-time information on mobile devices to enable new innovations, perhaps most notably what analyst house IDC dubbed “The 3rd Platform”
— a single, cohesive, symbiotic platform.  

This convergence will inevitably accelerate as disruptive health care regulations drive interoperability.

Michael F. Arrigo is managing partner of No World Borders health care practice. 

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