In June, Philip Boyce, senior vice president and chief revenue officer for Baptist Health, was among four panelists speaking at the HFMA Annual Conference about “Strategies to Reduce Payer-Provider Abrasion.”
A big part of that abrasion is due to prior authorization.
“Prior authorization is top of mind for every health system I know,” Boyce said.
A major reason is that providers will risk doing a procedure for free rather than wait for the patient’s insurance company to give prior authorization approval.
“More times than not we’ll do that, because it’s needed,” Boyce said.
Patients who need an urgent service don’t have a week to wait for prior auth, Boyce said. When surgeons provide the service before the authorization comes through, and it comes back denied, hospitals end up eating the cost. But since Baptist Health is serving the community, it will provide the service, get the denial and then spend months to overturn the denial, Boyce said.
In a sense, Baptist Health is providing a free service.
But there’s new hope from a recent commitment made by more than 50 insurers, including Humana and Elevance, to modernize the prior authorization process, Boyce said. This was announced just a week prior to HFMA, at the annual conference for insurers, AHIP 2025.
“Payers want to, like anybody, be more efficient,” Boyce said. “Payers don’t want to frustrate their network providers. They want their members to have a good experience. So I think payers don’t want to have broken systems if they can help it.”
For more on Boyce’s conversation with Susan Morse, executive editor of Healthcare Finance News, listen here:
Talking Points:
In January 2024, the Centers for Medicare & Medicaid Services released the CMS Interoperability and Prior Authorization Final Rule which requires payers to improve health information exchange.
The rule enhances certain policies from the CMS Interoperability and Patient Access Final Rule, with provisions going into effect in 2026 and 2027.
The rule pertains to Medicare, Medicare Advantage and Medicaid. Providers are waiting to see if commercial insurers will adopt the same standards for FHIR APIs and interoperability.
Baptist Health, as other health systems, has contracts with many different payers and plans, making prior authorization complex.
Most payers have vendors to handle the prior authorization process.
There’s no mandate to modernize denials. Providers are seeing more denials with greater specificity given for the denials.
Baptist Health pays a company to automate authorizations for imaging.
Ideally, the insurer would give an answer without the provider having to pay. “We shouldn’t have to pay to get an answer," Boyce said.
More About this Episode:
Many payers, providers unprepared for interoperability and prior authorization rule, WEDI finds
Interoperability in healthcare moving forward despite challenges
Providers pledge to ‘kill the clipboard’ in support of CMS Interoperability Framework
Humana pledges to simplify prior authorization process
Health plans make commitment to streamline prior authorization
Email the writer: SMorse@himss.org