State’s leading health plan takes step to ease capacity crunch in local hospitals; change will speed discharges & eliminate 14,000+ authorizations from the health care system
BOSTON , Nov. 6, 2023 /PRNewswire/ — Blue Cross Blue Shield of Massachusetts (“Blue Cross”) today announced that it will remove prior authorization requirements for home care services for commercial membersi beginning January 1, 2024. This means hospitalized members will not be required to get advance approval before being discharged to continue treatment at home.
Home care services include:
- Physical therapy
- Occupational therapy
- Home health aide and nurse visits
- Social worker visits
This change will eliminate 14,000 authorizations from the health care system, reduce administrative burden on clinicians, and help hospitals expedite discharges at a time when many are struggling with overcrowding. It will also reduce delays for members ready to transition their care from hospital to home.
“We know that prior authorization requirements can be an obstacle to access home care services – resulting in delayed discharges and hospital capacity issues,” said Dr. Sandhya Rao, Blue Cross’ chief medical officer. “Our goal is to simplify our members’ discharge path to home with services that meet their needs.”
The value of prior authorization
Prior Authorization (also known as “Pre-Certification”) is a process through which a clinician seeks advanced approval from a health plan to ensure that a service or treatment is covered, medically necessary, and not duplicated. It’s an important tool health plans use to ensure the services, drugs and devices that members receive are supported by current, credible medical evidence.
Expensive tests and procedures are often ordered that may not be supported by the most recent medical evidence. Blue Cross employs teams of physicians, registered nurses, and other clinicians to ensure that clinical decision making is consistent with clinical guidelines.
“The prior authorization process is critically important as our state confronts the challenge of health care affordability for families and businesses,” Rao said. “We have a responsibility to be good stewards of our members’ premium dollars and to ensure that services and treatments contribute to improved health outcomes and lower costs for our members.”
98% of Blue Cross claims do not require prior authorization. The health plan recently removed prior authorization requirements for other conditions including continuous glucose monitoring devices and supplies for Type 1 diabetes. Blue Cross was a leader nationally in removing prior authorization requirements for outpatient mental health treatment and transfers from the emergency department to inpatient mental health stays.
Health care affordability and prior authorization
Without prior authorization, health care premiums would increase. In fact, a recent study by Milliman concluded that removing prior authorization altogether could result in premium increases in the commercial market nationally totaling between $43 billion and $63 billion, or $240–$360 annually per member additional premiums. The report also estimated higher out of pocket costs for members if prior authorization was removed.
Automating prior authorization
Blue Cross recently completed a successful proof-of-concept pilot called “Fast Pass” to automate the prior authorization process and in turn alleviate administrative burden, decrease clinical review time, and increase clinician satisfaction. The pilot at New England Baptist Hospital focused on hip and knee procedures for 32 orthopedic providers over the course of a four-month period. 88% of prior authorization submissions were processed automatically in real-time. The overall impact on prior authorization approval time went from an average of nine days to an average of less than one day.
Blue Cross will continue to explore ways to automate prior authorizations in an effort to make the process frictionless for its clinical partners and members.
About Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of Massachusetts (bluecrossma.org) is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We are committed to the relentless pursuit of quality, affordable and equitable health care with an unparalleled consumer experience. Consistent with our promise to always put our members first, we are rated among the nation’s best health plans for member satisfaction and quality. Connect with us on Facebook, Twitter, YouTube, and LinkedIn.
i This change will apply to Blue Cross Medicare Advantage members beginning on January 1, 2025.