DETROIT, Sept. 7, 2023 – Blue Cross Blue Shield of Michigan, a national leader in streamlined prior authorization programs, is further reforming its process to relax approximately 20% of prior authorization requirements. This is part of Blue Cross’ ongoing effort to improve health care quality, experience, access and affordability for members, while also reducing administrative tasks for clinicians.
Prior authorization is important to validate medical necessity and the appropriateness of services and prescriptions. Blue Cross’ prior authorization program promotes quality and patient safety for members and provides assurance that the member gets effective care at the appropriate time.
“We are focused on partnering with the physician community to ensure that our members are getting timely care they need without roadblocks,” said James D. Grant, M.D., senior vice president and chief medical officer at Blue Cross Blue Shield of Michigan.“We are developing front line clinician-led pathways and systems to ensure the highest levels of safety and quality. Blue Cross Blue Shield of Michigan is known in the Michigan's clinical community for streamlining our prior authorization process through technology and an extensive gold-carding program.As part of our commitment to promoting optimal health and affordability of care for members and employers, we’re moving forward with changes to further improve the experience for both our members and clinical colleagues.”
To accelerate access to the highest quality care without undue delay, Blue Cross will also beexpanding its “gold carding” program.“Gold carding” streamlines prior authorization for physicians who have a proven track record of making appropriate evidence-based decisions by exempting them from third-party prior authorization approval processes.
“Our goal is to partner with clinicians to improve the prior authorization process so they can spend more time taking care of people and less time taking care of paperwork,” Dr. Grant said. “As a physician, I know first-hand what physicians and their teams experience every day.We seek to minimize the amount of time physicians, nurses and their staff spend on paperwork, the computer and the phone. After thorough analysis, we’ve eliminated hundreds of medical procedures that previously required prior authorization review, and we can give that time back to clinical partners to care for our members.”
Technology has helped to accelerate the prior authorization process at Blue Cross, with a significant majority of requests submitted electronically.
“Blue Cross processes roughly 87 million claims each year, and about 2.5 million, or roughly two percent, go through the review system,” said Jeniene Edwards R.N., vice president of Utilization Management at Blue Cross Blue Shield of Michigan.“Most prior authorization requests are submitted electronically and approved within seconds using automation that expedites the process. Our goal is to leverage multiple channels of technology for transparency and automation which also enables us to accelerate decisions to minimize disruption to our members.”
“As technology platforms continue to evolve, our long-term aim is to let these advances enable us to move from a world of “authorization” to “clinical decision support,” said Dr. Grant. “This way, all stakeholders, especially physicians, nurses, their staff and our members, will be able to quickly receive transparent, evidence-based decisions and status updates through their electronic medical record. This also ensures that coordinated care moves forward safely and without delay.”
Blue Cross Blue Shield of Michigan, a nonprofit mutual insurance company, is an independent licensee of the Blue Cross and Blue Shield Association. Blue Cross provides and administers health benefits to more than 4.7 million members residing in Michigan in addition to employees of Michigan-headquartered companies who reside outside the state. The company has been committed to delivering affordable health care products through a broad variety of plans for businesses, individuals and seniors for 80 years. For more information, visit bcbsm.com and MiBluesPerspectives.com.