Knowledge Center

Document outlines recommendations on addressing gaps that significantly reduce the administrative burden generated by prior authorization

WASHINGTON, DC — February 5, 2019 — WEDI, the nation’s leading nonprofit authority on the use of health IT to create efficiencies in healthcare information exchange and a statutory advisor to the U.S. Department of Health and Human Services (HHS), today announced the development of an industry white paper to address the high level of administrative burden associated with obtaining prior authorization. Written by the WEDI Prior Authorization Council (PAC), the paper outlines the work being done by the council to build a cross-stakeholder view of prior authorization in the US, as well as recommendations for policy development, standardization, and gap identification including both workflow integration and automation.

According to the paper, “The drum beat for administrative burden reduction from the Office of the National Coordinator (ONC) and the Centers for Medicare & Medicaid Services (CMS) has continued nonstop as all stakeholders confront the realization that a decade of investment in electronic health records and digital health information exchange feels like it has exacerbated, not solved, the problem of managing quality and cost without excessive administrative overhead.”

The document lays out observations, findings and recommendations by the PAC including:

• To begin to address the mindset change needed to solve the PA problem, WEDI should consider promoting the term “Administrative Automation” in place of “Administrative Simplification.”
• The PAC sees the need to promote a working group with the explicit charter to set expectations for EHR, HIS, PMS and other vendors supplying software and services to the payer and provider communities. This working group would be charged insuring the development of a reference architecture that coordinates the work of all the stakeholder groups to achieve a result that can be characterized as “Single Action Order Entry.”
• Lastly, the industry needs to avoid “standards wars.” The harmonization of the FHIR, C-CDA and X12 standards development efforts needs to be a joint priority among the stakeholders.

Formed under the guidance of the WEDI Board of Directors to create a forum for communication between primary stakeholders in the prior authorization process, the 12-member lead PAC includes the American Medical Association (AMA), America's Health Insurance Plans (AHIP), Blue Cross Blue Shield Association (BCBSA), Council for Affordable Quality Healthcare (CAQH), the Cooperative Exchange (CE), Healthcare Administrative Technology Association (HATA), Health Information Management Systems Society (HIMSS), HL7, Medical Group Management Association (MGMA), National Council for Prescription Drug Programs (NCPDP), WEDI and X12.

About WEDI
WEDI is the leading authority on the use of health IT to improve healthcare information exchange in order to enhance the quality of care, improve efficiency, and reduce costs of our nation’s healthcare system. WEDI was formed in 1991 by the Secretary of Health and Human Services and was designated in the 1996 HIPAA legislation as an advisor to HHS. WEDI’s membership includes a broad coalition of organizations, including: hospitals, providers, health plans, vendors, government agencies, consumers, not-for-profit organizations, and standards development organizations. To learn more, visit www.wedi.org and connect with us on Twitter and LinkedIn.