Blue Cross Implements Reforms on Prior Authorization to Support Doctors, Members
Blues Perspectives
| 3 min read
At Blue Cross Blue Shield of Michigan, we know the relationship between doctors and members is a powerful one. As a company created by doctors 84 years ago, we value that relationship – and work with providers to ensure members get the right care, at the right time, in the right setting. Our clinical expert teams continually analyze our policies and procedures so we can improve access to care for our members, while ensuring health care professionals are supported in their work on the front lines.
We’ve led the way in streamlining programs to improve health care quality, experience, access and affordability– and are now working to further streamline our processes to support clinicians with the tools they need to help members.
We are making changes to improve the prior authorization process, which is the method doctors and their clinical teams use to request approval from insurers for certain tests, treatments, prescriptions or equipment:
- We’re clearing roadblocks: We are eliminating 20% of prior authorization requirements, decreasing the need for additional review on hundreds of requests and improving processes for providers so they can focus on delivering high-quality care.
- We’re supporting physicians: We are expanding our “gold carding” program, where physicians who have a proven record of evidence-based decisions can be exempt from third-party prior authorization approval processes in certain circumstances.
At Blue Cross, we are both clinicians and members– and we are always ready to help improve the system with our combined expertise and experience.
“Our goal is to partner with physicians so that they can spend more time taking care of people and less time taking care of paperwork,” said Dr. James D. Grant, chief medical officer and senior vice president at Blue Cross. “As a physician who is also married to a physician, I see firsthand what physicians and their teams endure every day. I cannot be clearer that my top priority is to minimize the inordinate amount of time physicians, nurses and their staff spend on administrative tasks, which pulls them away from direct patient care.”
Each year, Blue Cross processes about 87 million claims. About two percent, about 2.5 million, go through the prior authorization process.
We’ve made significant strides in using technology to accelerate this request process in the past. A significant majority of prior authorization requests were already being submitted electronically. As of June 1, 2023, all prior authorization requests are submitted electronically, unless there is a technical or electronic issue. In addition, requests are reviewed and decided within the new nine-day turnaround timeframe required by state law (this timeframe will be reduced to seven days beginning June 1, 2024).
We’re working to further reduce the administrative burden on doctors and their clinical care teams, so they can focus on taking care of members. This includes making medical policies easily accessible and providing up-to-date lists of benefits and services that require prior authorization. These steps support Blue Cross’ long-term goal to evolve prior authorization from a clerical process to one that is more focused on clinical decision support.
How do I find out more about prior authorization?
At Blue Cross Blue Shield of Michigan, we are committed to making sure that you have all the tools you need at your fingertips through our online member portal at bcbsm.com and the BCBSM mobile app.
We’re made some updates recently and you can now get information about prior authorizations through the portal and on the Blue Cross website.
If prior authorization is required for a service, your health care provider will request it on your behalf. You do not have to do anything.
If you have any questions, please call using the phone number on the back of your ID card.
