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95% adopted electronic claim submission

87% of physicians have adopted HER

70% adopted e-prescribing

8% adopted prior authorization ePA

Unlike electronic claims, e-prescribing and eligibility
checking individual states have not forced
insurance companies at the local level to adhere to
long-established standards, delaying the ePA adaption.

Moving beyond the basic information requirements
such as requesting physician, patient, insurance,
demographics, CPT, and ICD-10 codes, the insurance
companies are looking for justification why the testing
was necessary. Often this requires supporting
documentation such as previous treatments, medical
records, and lab results to support the request.

Pre-authorization for outpatient services is reasonably
As the demand for manual and electronic PA increases, managed; however, in a physician office setting if for
decisions need to be made based on the cost of doing example, a molecular test is ordered the pre-authorization
business in a pre-authorization environment as the current process for laboratory testing is not well defined.
workflow is not sustainable. Physician practice management vendors are slowly sorting

• Continue to develop an in-house process with out the pre-authorization puzzle; however, laboratories
dedicated staff that specializes in this process? could seize this as an opportunity to provide a better
• Outsource this process to vendors who specialize experience for their physician clients by championing
in the handling of ePA? change in the current process. Laboratories could build
• Deploy a software solution to handle the ePA a decision support engine to determine if prior
demands that integrate seamlessly within authorizations are needed or not needed based on
the physician’s practice management/EHR predefined criteria such as type of procedure, CPT,
system through API’s or an HL7 interface? ICD-10, and insurance could be a good start.
Laboratories are the experts tracking turn-around-times
Why is the process of migrating from a cumbersome TAT for tests; perhaps they can bring their expertise
manual process to ePA so slow considering the standard to create TAT for PA requests.
has been around for years? The reason for this technology
gap is due to the challenges of software vendors to
reconcile the variables of over 2000 insurance companies,
each with their own prior authorization request form
and procedures.