Epic Systems is working with medical care providers and an increasing number of health insurers to modernize prior authorization, the process of insurers reviewing hospital admissions and medications.
Meeting this week at its Verona, Wis., headquarters for its annual users group meeting, the company said it is successfully helping doctors and hospitals across the U.S. “implement real-time prior authorization checks” with health insurers including UnitedHealth Group’s United Healthcare, the nation’s largest health insurer, and CVS Health’s Aetna “using a new industry-standard API called Coverage Requirements Discovery (CRD).” Epic said another 16 health insurers are testing its system.
“Clinicians and staff can easily check prior authorization requirements in Epic when placing an order or before scheduling an appointment, eliminating the need for phone calls, faxes, or retyping information into separate insurance portals,” Epic said in a statement released Monday.
Epic’s announcement comes at a time health insurance business practices are under fire from patients, physicians, lawmakers and regulators at both the state and federal level to reduce or get rid of prior authorization. Just last week, a analysis by KFF showed that insurers denied between 12% and 18%, approximately one in eight, of prior authorization requests last year for Americans enrolled in either privatized Medicare Advantage coverage for older adults, Medicaid coverage for poor Americans or individual coverage under the Affordable Care Act, also known as Obamacare.
But it has been a priority of the Centers for Medicare & Medicaid Services and the Trump administration to speed up implementation of electronic prior authorization across the healthcare industry.
Epic confirmed the first healthcare systems to implement this new feature are Ochsner Health, Froedtert ThedaCare Health, Denver Health and Summit Health.
Epic, which has been led by its 83-year-old founder Judy Faulkner for 47 years and is best known for its dominance in the electronic health record software space, is forming closer ties with health insurance companies while pushing deeper into AI in a healthcare industry known for its complexities, fragmentation and consumer frustration. Epic’s technology is already used by 3,500 hospitals, more than 71,000 clinics and some 325 million patients worldwide.