- Nonprofit health plan's prior authorization platform
solution built on Salesforce Health Cloud will work within
physician systems to gather relevant clinical data from electronic
health records and streamline 20+ disparate systems; members and
physicians will get prior authorization in near real-time
- Testing begins in early 2025 with limited rollout
later in year; near real-time prior authorization available
January 2026; additional capabilities
to follow
OAKLAND,
Calif., Oct. 21, 2024 /PRNewswire/ -- Blue Shield
of California and Salesforce
(NYSE: CRM), the #1 AI CRM, are teaming up to solve a
significant healthcare challenge — providing physicians and their
patients prior authorization answers in near real-time, rather than
days. Together, Blue Shield and Salesforce will make prior
authorization simpler, faster and more transparent. The platform
solution, which will be built on Salesforce Health Cloud, will also
connect members to personalized health support by automatically
alerting care teams of prior authorization requests.
Health plans rely on prior authorization to ensure certain
recommended treatments and services are safe, evidence-based and
high-value for their members. However, according to the American
Medical Association's annual survey, 78% of physicians said issues
with prior authorization can lead to patients foregoing care. This
is in part due to outdated and inefficient healthcare industry
processes:
- About two-thirds of prior authorization requests are submitted
manually or partially manually, including by fax machine.
- Submissions that lack complete clinical information slow the
process.
- Outdated electronic systems waste time and resources.
- All the while, patients are left without answers, worried about
their next steps in care.
Blue Shield will use Health Level Seven (HL7) Fast Healthcare
Interoperability Resources (FHIR) standards to create technology
that will streamline 20+ disparate systems that exist today
into one process that integrates with physicians' current
workflow.
Future Experience Will Be Fast, Efficient and Easy
Prompted by the physician, the platform solution will search a
patient's electronic health record for relevant clinical
information and compile it into a pre-populated electronic form.
Physicians will be able to submit requests from their systems on
the spot — no fax machine needed — and members will receive answers
during their medical appointments. Modifications or denials will
always be made by a medical director or licensed
clinician.
A small number of cases may require clinical consultation. When
that happens, physicians will receive a message in near real-time
detailing what is needed to complete the authorization, and options
to begin a peer-to-peer clinical consultation. This currently can
take several days. In the future, this can happen within hours,
depending on the requesting physician's availability. Throughout
this process, members will receive status updates in their Blue
Shield member app, giving them a new level of transparency.
"Prior authorization was never meant to be a barrier or a
burden. As a health plan, it's our responsibility to ensure safe,
evidence-based, high-value care for our members, and we know it can
be an easier process for everyone," said Paul Markovich, chief executive officer, Blue
Shield of California. "That's why
we are taking the bold step to make it as easy as using your credit
card, while enabling more coordinated, personalized support for
members. It is time for the industry to let go of fax
machines."
"For years, we've heard that technology will be the answer
to systemic issues in health care, but few solutions have made a
scalable impact," said Jeff Amann,
executive vice president and general manager, Salesforce
Industries. "With Blue Shield of California, we're rebuilding the prior
authorization process with new innovations that support near
real-time decision-making so providers can more quickly,
transparently and compliantly deliver the attentive care their
patients deserve."
Moving the Healthcare Industry Forward
Blue Shield will go beyond current efforts in this space: the
Centers for Medicaid and Medicare Services' Interoperability and
Prior Authorization Final Rule requirements; efforts by health
plans that focus on reducing the number of treatments that require
prior authorization; and gold carding, which removes prior
authorization for physicians that meet certain requirements for a
set period of time.
"As a practicing physician, I'm proud that we're taking on this
challenge to build a solution that allows providers to focus on
delivering care — why they became physicians in the first place —
rather than adding to the administrative burden," said Ravi
Kavasery, M.D., chief medical officer, Blue Shield of California.
Enabling More Holistic, Comprehensive Care
The new platform solution will work alongside Care Connect —
Blue Shield's care management system — creating a clinical
infrastructure that shifts the focus from the moment of medical
necessity to ongoing, preventive care and wellness. In the future,
a prior authorization request will automatically alert the health
plan's team of nurses, social workers and behavioral health
specialists that a member may need new or increased health
support.
For example, if a physician requests approval for a continuous
glucose monitor, care teams are automatically prompted to contact
the member with information on diabetes reversal programs available
through their Blue Shield benefits. In this way, prior
authorization enables members to get more personalized, coordinated
care.
Creating a Healthcare System Worthy of Family and
Friends
This is Blue Shield's latest bold move to reimagine health care.
In 2023, the health plan announced Pharmacy Care Reimagined, its
groundbreaking model to transform prescription drug care. Earlier
this month, Blue Shield announced a collaboration to slash the cost
of the world's best-selling drug, Humira. Blue Shield has developed
new payment models in collaboration with physician and hospital
partners to bring better value into the healthcare market and bend
the cost of health care trend. By the end of 2024, all members will
have access to their health information through Blue Shield's
Member Health Record.
About Blue Shield of California
Blue Shield of California
strives to create a healthcare system worthy of its family and
friends that is sustainably affordable. The health plan is a tax
paying, nonprofit, independent member of the Blue Shield
Association with more than 4.8 million members, over 7,100
employees and more than $25 billion
in annual revenue. Founded in 1939 in San
Francisco and now headquartered in Oakland, Blue Shield of California and its affiliates provide health,
dental, vision, Medicaid and Medicare healthcare service plans in
California. The company has
contributed more than $77 million to
the Blue Shield of California Foundation in the last three years to
have an impact on California
communities.
For more news about Blue Shield of California, please
visit news.blueshieldca.com.
Or follow us on LinkedIn or Facebook.
CONTACT: Amanda
Wardell
Blue Shield of California
510-607-2359
media@blueshieldca.com
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SOURCE Blue Shield of California