Benefits of CMS Interoperability and Prior Auth
Benefits of using Prior Authorization Prior authorization support (PAS) is a process that healthcare organizations use to ensure that the treatments, procedures, and services provided to patients are medically necessary and covered by insurance. The Fast Healthcare Interoperability Resources (FHIR) standard is a data format that can be used to facilitate the exchange of information related to prior authorization between healthcare organizations, payers, and patients. In this document, we will discuss how healthcare organizations can use and benefit from FHIR-based prior authorization.
One of the main benefits of using FHIR for prior authorization is that it allows healthcare organizations to automate the process of requesting and receiving authorization from payers. This can be done by using FHIR-based APIs (Application Programming Interfaces) to electronically submit prior authorization requests, as well as to receive responses from payers. This can save time and reduce the need for manual data entry, which can result in fewer errors and faster approval times.
Source: DaVinci PAS (https://build.fhir.org/ig/HL7/davinci-pas/)
Another benefit of using FHIR for prior authorization is that it allows healthcare organizations to access a patient's medical history and insurance information in real-time. This can be done by using FHIR-based APIs to query payers for this information, which can be used to make more informed decisionsabout the medicalnecessity of a treatment or procedure. This can help to improve the quality of care provided to patients and reduce the risk of denied claims.
Source: DaVinci PAS (https://build.fhir.org/ig/HL7/davinci-pas/usecases.html)
In addition to these benefits, FHIR-based prior authorization can also help to improve communication between healthcare organizations, payers, and patients. For example, FHIR-based APIs can be used to send automated reminders to patients about upcoming appointments or procedures, as well as to provide patients with real-time updates on the status of their prior authorization requests. This can help to increase patient engagement and satisfaction, which can lead to better health outcomes.
In summary, healthcare organizations can benefit from using FHIR-based prior authorization in several ways, including automation of the prior authorization process, real-time access to patient's medical history, insurance information, and improved communication between healthcare organizations, payers, and patients. Implementing FHIR-based prior authorization can help healthcare organizations to improve the quality of care provided to patients, reduce the risk of denied claims, and increase patient engagement and satisfaction. It's worth to mention that FHIR is an open-source standard, which means that healthcare organizations can use it without incurring additional costs.