Blue Shield of California partners with Salesforce on prior authorization

According to Fierce Healthcare, prior authorization continues to be a pain point for many physicians who are already struggling with limited time and resources. Patients can also be negatively impacted if they are forced to wait for critical services. In a recent survey from the American Medical Association, 78% of physicians said prior authorizations can cause patients to skip care.

"It's just really inefficient. It's painful, it's stressful for patients," said Paul Markovich, CEO of Blue Shield of California. "And we've heard physicians, a lot of them, talk about how some of their patients end up not accessing the care they're recommending because the process takes so long and is so difficult."

To help streamline the process, Blue Shield of California has teamed up with Salesforce to create a new tool built using Salesforce Health Cloud. When a physician submits a prior authorization request, the platform will search a patient's EHR for any relevant clinical information and use it to fill out a pre-populated form that physicians can submit to Blue Shield.

If a case requires clinical consultation, the requesting physician will receive a message explaining what information is needed within a few hours instead of days. Patients will also be able to receive updates on their prior authorization requests through the Blue Shield member app. Any denial of a prior authorization request will be made by a medical director or licensed clinician.

Currently, testing for the tool will begin in early 2025, with a limited rollout occurring later in the year. Near real-time prior authorization is expected to be available starting January 2026.

According to the companies' leaders, the tool will help providers who are burdened by administrative work, as well as patients who often wait weeks for care when their prior authorization decisions take a while.

"We have completely automated and digitized the process," Markovich said, noting that the near instantaneous nature of the tool would "take a lot of the frustration and stress for patients and physicians out of the system."

The companies also noted that the tool could help ease frictions about prior authorization between payers and providers. Although providers often feel like prior authorization slows down the care process, payers say that it is necessary to prevent unnecessary care and reduce costs.

"There's no finger-pointing if there's no problem," said Jeff Amann, EVP and general manager of Salesforce Industries. "That's the objective. Of course, there will be exceptions, but those exceptions are learning opportunities for the business system."

Overall, Markovich said the companies hope that the tool can help make the prior authorization process as easy as using a credit card.

"To me, the biggest thing we can do — and this is where the health plans I think are most at fault — is create a system where it can be like using a credit card," Markovich said. "Sometimes your credit card will be like, 'Whoops, wait, call this number.' That's going to happen in this process, too, and you can immediately get somebody on the phone. You can talk to a clinician, you can schedule at a convenient time, there's always going to be a human in the loop for any kind of time that we can’t fully approve prior authorization."

Potential concerns over automation for claims reviews

According to Healthcare Dive, there is growing scrutiny of insurers using automation to review patient claims.

Last month, the Senate Permanent Subcommittee on Investigations released a report criticizing three of the country's largest Medicare Advantage insurers for using predictive technology to allegedly deny patients access to post-acute care. These insurers have also been sued over the use of automated decision tools, with plaintiffs arguing that the technology improperly denied claims en masse.

However, Markovich said that Blue Shield's automated tool will be different from those of its competitors. "Any denial would have to happen through the judgment of a trained human being," he said, adding that a human is "kept in the loop" and will review any prior authorization requests that need more information or are flagged for denial.

Blue Shield also promised to have more robust human supervision, as well as conversations between the insurer and physicians about why a request was flagged.

"If we can't approve it, there's two things that are going to happen. One is, it'll be clear why — we will be able to say, here's the things that we aren't seeing, like where there is no evidence of [past treatment]," Markovich said. "Then, that physician can speak to whoever the appropriate medical director or peer is about that and have a peer-to-peer conversation right there in the moment or at a conveniently scheduled time. That has to happen in order for us to get to a 'no.'"

Advisory Board's prior authorization resources

For more insight into technology and prior authorization, check out these Advisory Board resources:

• How plans are (and aren’t) using AI to automate prior authorizations
• Addressing plan-provider friction: 3 insights from Optum’s Payer-Provider Abrasion survey
• How BCBS of South Carolina Created a Live Prior-Authorization Tracker
• Your 3-step guide to creating an effective denials-prevention strategy

(Minemyer, Fierce Healthcare, 10/21; DeFreitas, HealthLeaders, 10/28; Plescia, MedCity News, 10/22; Vogel, Healthcare Dive, 10/22)