It’s no secret that payers and providers have a historically antagonistic relationship. This struggle was noted in KLAS’ recent “Points of Light” report, which optimistically explored case studies of successful payer-provider collaborations.
After diving deeper into the case studies focused on reducing administrative burden through automation, one thing became clear: payers and providers still struggle to effectively collaborate, but health tech vendors can act as a linking agent to improve outcomes for both sides.
One such case study detailed how health tech company Olive automated the prior authorization process for both Duluth, Minnesota-based Essentia Health and Guidewell. The technology improved efficiency for both organizations, though Essentia Health did not directly collaborate with any payers during this initiative, nor did Guidewell collaborate with providers.
Partnering with Olive allowed Essentia Health to take matters into its own hands to speed up the notoriously onerous prior authorization process. Instead of pursuing direct collaborations with the multitude of payers the health system bills, Essentia Health chose to implement Olive’s technology, which is compatible with most payers.
When Essentia Health went live with the technology in May 2021, Olive was able to automatically pull up coverage guidelines for 80% of the health system’s payers, said Jamie Madrinich, who works as a manager in Essentia Health’s pre-service department. She said that number is now closer to 90%, and the initiative has reduced the health system’s prior authorization turnaround time by about eight days. By eliminating much of the back-and-forth communication staff members conduct with payers, the automation technology has freed up their time to focus on less manual tasks.
In another case study, Cedar, a company focused on healthcare payment technology, stepped in to improve the prior authorization process for both Conway Medical Center in Conway, South Carolina, and Palmetto GBA. Similar to Essentia Health and Guidewell’s separate partnerships with Olive, Cedar’s automation technology was able to reduce manual tasks for staff members at both Conway Medical Center and Palmetto GBA.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Cedar created a tool that links Conway Medical Center’s EMR to the software used by Palmetto GBA so that prior authorization information can be sent and received more quickly. The automation technology reduced the prior authorization turnaround time at Conway Medical Center to less than 48 hours, according to Anshul Amar, co-chief maker at Cedar.
“Payers and providers are really complex, multifaceted organizations that have very elaborate business procedures,” he said. “They’ve evolved their own different ways of working, so one of the ways that an organization like Cedar can come in to really bridge that gap is by allowing them both to work the way that they work best by bridging data and workflows.”
Companies like Cedar and Olive can often “translate” between payers and providers, Amar noted. He said that instead of a provider completely altering its workflow based on what a payer asks it to do, health tech vendors can intervene to figure out how the two entities can comply with each other in a way that is efficient for their business goals and organizational missions.
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