Last time, I shared with you some insights from our Senior Medical Director, Dr. Larry Simon, about why prior authorization is an important way Louisiana Blue protects our members’ health and safety while being good stewards of their premium dollars. I addressed some common questions we hear from members to explain why this process exists and how it operates.
Now, I want to look at prior authorization from the provider’s perspective and share some ways we are making this process easier and more effective for them. Because at the end of the day, this benefits you, our shared customer—the patient and the member. After all, when your doctor and your insurance company work together, you get a better experience.
As we grow and cover more members who need more and more healthcare services, making sure they are each getting the right care in the right setting at the right time is a huge challenge for us and our network providers.
That’s why in the past couple of years we’ve invested in new technology that speeds up and simplifies these important decisions.
Better Sharing Upstream to Avoid Denials Downstream
I’ve talked in an earlier Straight Talk about our work to drive greater collaboration with providers through the Epic Payer Platform.
With Epic in place, prior authorizations and provider consultations are MUCH more efficient and move faster. That’s because the medical providers and our clinical team have all the data in one place to make rapid and accurate decisions.
More than 70% of our members are seeing a healthcare provider who uses Epic. Now that Louisiana Blue has moved its clinical functions onto the same platform, it’s easier for us to securely exchange data with them so we all get a complete picture of someone’s health.
Often, doctors using Epic can get real-time feedback or information from our clinical team while the patient is in their office. This could be based on claims data, calls with a health coach or any social issues, such as lacking transportation or having financial difficulties that the member has shared.
The provider can use this information to modify treatment orders while the patient is there to talk through it with them. And that saves a lot of follow-up time and requests for additional information on our side. Which, as I mentioned last time, accounts for a lot of cases where a prior authorization request is not approved.
As of the end of 2024, we increased our auto-decision prior authorization rate (these are cases when all the information is submitted electronically up front and no further case review or documentation is needed) from 24% to 37%, just by moving these processes to Epic. We are planning to add more healthcare systems and provider sites to Epic in 2025, which we hope will help more providers get faster determinations and have an easier time submitting requests.
By investing more time and resources to share information with providers up front, Dr. Larry and the rest of our care team feel confident we can avoid more denials downstream.
The Golden Ticket – er, Card
Another approach we are piloting is called “gold carding.” The way this works is when healthcare providers consistently get their prior authorization requests for drugs or treatments approved—which means they are always sending in the proper documentation and information and we rarely have to go back to them and ask for more—they are given a “medical benefit of the doubt.”
If their patterns of care meet certain criteria—like being approved 95-99% of the time when they submit a prior authorization request—then they are “gold carded.” This status means they get Louisiana Blue’s approval faster and with fewer levels of prior authorization to deal with compared to other providers.
We implemented our first Gold Card program in late 2023 after working with providers, our state legislators and other stakeholders to decide what structure made the most sense. That involved us collaborating to look at everyone’s needs, what we wanted to accomplish and what we could learn from best practices in other states.
Initially, we are looking at prior authorization requests for high-tech imaging services, which has long been a treatment area with medically unnecessary overuse. For the Gold Card providers, we’re estimating that this program could eliminate 35,000 review requests from their annual workloads.
Right now, gold carding is a pilot. When the program entered its second year last October, we gold carded 345 new providers who met the criteria to begin participating. As we try out the Gold Card program and see how it goes, we’re open to adding more provider specialties or more categories of requests.
Containing Drug Costs
In 2023, Louisiana Blue spent almost $1 billion just on our members’ drugs. Did you know that worked out to almost 30% of all the premiums our members paid? Did you know that member contributions in the form of copays and deductibles only covered about 13% of that total spending, and your premiums paid the other 87%?
With that kind of money on the line, it’s very important that we make sure our members are prescribed drugs that are clinically effective AND cost-efficient.
Our pharmacy benefit manager already provides a lot of automation with reviewing prescriptions on our behalf nearly a million times a month by enforcing our drug formulary, which varies in scope from plan to plan.
But drug prices continue to skyrocket, and off-label prescribing becomes a bigger and bigger expense. This means prescribing a drug that is covered for one condition to address an entirely different condition. As care costs go up, premium costs go up to cover those services. A great example is GLP-1s, which I wrote about in 2024. Right now, these drugs are approved and covered for diabetics, but there is plenty of off-label prescribing going on and we need to keep a close watch on the circumstances under which we pay for them. Based on these trends from the past few years, we need to tightly manage drug spending to keep premium costs in line.
All these things keep me awake at night and make me realize that our prior authorization process, which is managed by people with clinical backgrounds, has never been more important. As a member myself, I know it can be annoying when a request gets denied and you or your provider need to take the time to send more information.
But the Straight Talk is, here at Louisiana Blue, we are very different from our for-profit competition in many ways, and prior authorization is no exception. Our top priorities remain using our very experienced, highly informed clinical staff to ensure you get care that is appropriate, timely, safe and cost-effective, in that order. It’s the least we can do to be good stewards of your money.
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