Tyler Wince, senior vice president and chief product officer at Myndshft, leads the product and data science teams responsible for Myndshft’s end-to-end prior authorization platform. He discusses the biggest challenges relating to prior authorization and benefits for diagnostic and genomic labs and how automated technologies can help solve these issues.
Q: What are the biggest challenges relating to prior authorization and benefits for diagnostic/genomic labs today?
A: Diagnostic and genomic testing is evolving rapidly with new tests and panels emerging every week. As genomic testing and therapy options continue to expand, insurance companies are keeping pace by creating additional prior authorization and documentation requirements. It’s not all that surprising, given the significant costs and novelty of these tests. Insurance companies view prior authorization as a way to contain costs and ensure their members receive appropriate care, but it certainly adds to the administrative burden that diagnostic and genomic labs face today.
Q: How is technology helping to solve those challenges?
A: Aside from newer portal technologies, payers have done little to enable better authorization processes for providers. While these portal systems make prior authorization submissions easier, they don’t simplify or eliminate burdens related to identifying prior authorization requirements prior to submission or ongoing status monitoring. Automated technology offers tangible solutions to the prior authorization problem. Integration to LIMS systems provides access to what we call “Collective Healthcare Intelligence,” enabling providers to extract data directly from the patient order, verify submission criteria, and receive status updates without any manual work. This technology delivers a huge impact, enabling labs to manage a high patient volume, despite the complex nature of care needs.
Q: What key factors should labs be looking at when choosing a technology solution for prior authorization/benefits?
A: When considering benefits verification and prior authorization technology, diagnostic and genomic testing labs need to know:
- Will the solution integrate within your LIMS system? Inputting the same data in multiple places plays havoc on productivity. Direct integration with your system of record means that your staff can check benefits or submit prior authorizations more efficiently and with less opportunity for human error.
- Can the technology surface only necessary information? Sifting through information to find what’s relevant is a time-intensive undertaking. Data parsing reduces the noise so your staff only sees the benefits applicable to a particular episode of care.
- Does the solution cover a significant portion of the patient population? Some solutions only service 10-30% of the patient population. This simply adds to the administrative burden, requiring staff to learn and manage multiple workflows, depending on each patient’s insurer. Labs should look for technologies that offer comprehensive payer connections that easily scale to meet evolving patient populations.
There are other questions, obviously, like what kind of ROI can be expected? But the three questions above represent a good starting point for narrowing the field of potential technologies down to top contenders.
Q: The HHS Office of the National Coordinator for Health Information Technology recently published a Request for Information seeking public comments on certification standards for the development and implementation of electronic prior authorization IT products. What are your thoughts on those standards?
A: The conversation around updated ePA [electronic prior authorization] standards are going to help move the industry forward from the payer side of the equation. The intent of future certification standards is to move the prior authorization process from a document-driven approach to a data-driven approach. This comes, primarily, by way of implementing new API [application programming interface] requirements and standards, as well as requiring management of authorization guidelines in a digital format. While this won’t eliminate providers’ need for a solution to manage the submission and status checks of submitted prior authorizations, furthering interoperability and consistency is definitely a good thing.
Q: How do you expect things to develop going forward when it comes to prior authorization and benefits challenges and solutions for labs? Where are things headed?
A: Managing prior authorizations via large documents and manual effort is going the way of dinosaurs. Shifting to a data-driven approach will transform not only how prior authorizations are submitted, but how lab referrals are shared and how results are ultimately reported. The firm commitment to HL7 FHIR [Fast Healthcare Interoperability Resources] standards will accelerate real-time communication between systems, quickly surpassing the current HL7 v2 and [Accredited Standards Committee] X12. Ultimately, I expect we will see prior authorizations take place instantaneously when an order is placed for lab services, eliminating the bottlenecks that delay care today.
Tyler Wince joined Myndshft in 2016 as senior vice president and chief product officer. For over a decade, Wince has held leadership roles across education, health care, and information technology. He is an experienced software engineer and data scientist with a demonstrated history in working in information technology and health care. Wince is a graduate of the University of Arizona with a degree in molecular and cellular biology and a master’s of education in teaching and teacher education. He currently resides in Gilbert, AZ.