Southeastern Pennsylvania-based insurer Independence Blue Cross (IBX) and Penn Medicine have worked together to reimagine a process that cuts the time providers spend on the administrative work for prior authorization of certain imaging tests.
The news coincides with announcements that several large health insurance plans have made a series of commitments to streamline, simplify, and reduce prior authorization.
The IBX program was launched in 2023 as part of a longstanding collaboration between the health system and IBX to develop innovative programs that improve care and help contain costs. The program's goals are to get patients to care and a diagnosis faster and to save both providers and IBX time on prior authorization requests for outpatient scans (such as, CT, PET, and nuclear medicine scans, MRI and echocardiograms). Early results have led IBX to expand the program to other health system partners.
Providers with a documented, 12-month history of ordering imaging tests in alignment with IBX’s criteria and Penn Medicine’s electronic health record-based decision tool are eligible to be in the program. Those providers then receive automatic prior authorization for certain common scans. This process helps to reduce the time providers would have spent getting approvals from IBX. It also speeds up the time between when a scan is ordered and when a patient receives the test. IBX and Penn Medicine also share data and accountability to ensure that providers in the program continue to follow best-practice guidelines on an ongoing basis.
Results from the program for IBX members and Penn Medicine patients and providers include:
• 83 percent of outpatient radiology requests are now approved in one-tenth of the time the process would typically take.
• A 9 percent decrease in low-value requests — tests that are unlikely to provide useful information for diagnosing or treating a patient’s condition or can be swapped for simpler or safer alternative — among clinicians in the program. Among providers who have expressed an interest in being in the program, requests for these types of tests also dropped 11 percent.
“This program’s impact is impressive. The results speak volumes and show that it is truly setting a new standard for thoughtful and efficient care management,” said Rodrigo Cerdá, M.D., M.P.H., senior vice president of health services and chief medical officer at Independence Blue Cross, in a statement. “We created the program to address the growing need, both locally and nationally, to reimagine and simplify the prior authorization process. This is a great collaboration with our network that allows us to make the process easier, while continuing to ensure our members receive efficient and clinically appropriate care at the right place and right time.”
“Our goal is always to provide the best possible care to patients, and part of that means continuously improving the systems that make care more efficient and accessible,” said Mitchell Schnall, M.D., Ph.D., senior vice president for data and technology solutions at Penn Medicine, in a statement. “This new system streamlines the process for everyone involved — providers spend less time on administrative tasks, patients face shorter wait times for scan approvals, and we see fewer late cancellations and more efficient scheduling with fewer gaps.”
IBX also implemented the Epic Payer Platform in 2024, which it expects to result in further acceleration of access to care. The platform will enable smoother information exchange for quality and coordination of care, IBX said.
“Prior authorization serves an important purpose,” added Cerdá. “It helps ensure care aligns with the latest medical guidelines. While removing all prior authorizations could negatively impact members or increase costs, we are collaborating with providers to improve the process.”
The program was initially launched with Penn Medicine because the health system already had a clinical decision support tool embedded in its electronic medical record that largely aligned with criteria for prior authorization. The program’s success so far has prompted IBX to expand it to other providers in its network. To date, it has been expanded to Abington Medical Specialists and Temple Health. IBX is having discussions with other providers in the region as well and expects that the program will continue to grow.
