Aetna seeks 'sweet spot' in plan to automate prior authorizations

Aetna is leaning into technology it believes will alleviate patient and provider headaches from burdensome utilization management rules, Chief Medical Officer Dr. Cathy Moffitt said.

To expedite care and reduce administrative obstacles, the health insurance company intends to automate about one-third of preapproval requests from providers this year, Moffitt, also a senior vice president at parent company CVS Health, said in an interview. But Aetna is walking a fine line as health insurers face backlash over how they incorporate technologies such as algorithms and artificial intelligence into the preapproval process.

Related: Prior authorization targeted by more and more states

UnitedHealth Group and Cigna are fending off lawsuits that allege they use AI and other automated tools to deny medical claims. The lawsuits haven’t discouraged insurers such as Aetna and Health Care Service Corp. from finding more use cases for automation in utilization management, which they maintain will smooth the contentious process for providers and patients.

This interview has been edited for length and clarity.

Many providers and patients bemoan utilization management. Illuminate its purpose from an insurer’s perspective.

Utilization management is a fundamental commitment we make to our members to make sure they receive the right care at the right time for the right reason. But we also acknowledge it isn't always easy.

UM has its place in patient safety and the integrity of the care that is delivered. We believe that complete removal of this process will put patients at risk. We want to find the sweet spot where we continue to protect patient safety [and] clinical integrity, and eliminate hassles.

How is Aetna eliminating hassles for providers?

Providers sometimes consider this to be more difficult than just writing an order and getting a service. In deference to that, we have invested a lot into technology to streamline the experience as best we can for providers. We have looked historically at a lot of services that are always approved, and we have made those eligible for automation.

Let me be clear: We automate approvals. We never automate medical necessity-based denials. We have a fleet of board-certified medical directors, and they are the only ones who may render a denial based on medical necessity for a service. That's extremely important because we're trying to find the right balance between patient safety, fiscal responsibility, and member and provider experience.

What has Aetna found is the most effective way to design and implement utilization management tools?

Two ways: looking back and looking concurrently at things. We have spent a lot of time looking at the services our providers have historically requested, and we have designated certain providers who have very consistent track records of requesting services that meet medical necessity guidelines. We feel it's important to allow them — in many cases, for certain services — to be UM-exempt for a period of time for those services, traditionally known as 'gold carding.'

We also continue to watch those providers and ensure the pattern of prior auth that got them the differentiation status continues to happen, which we call intelligent monitoring.

Is Aetna considering changes to its prior authorization requirements?

We look at prior auth regularly — at least every six months and sometimes more often. We look at it through the lens of impact to patient safety, cost, and the potential for fraud, waste and abuse.

The intention is to preserve the good that UM brings and try to eliminate hassles. This is a constant process. By the end of this year, we aim to have about 30% of the requests we get sent in to be automated because they are approvable services.

How does your strategy affect the health of your members?

UM is a great opportunity to understand the care journey of the member. Many times, in the process of looking at a request for services, we have an opportunity to say, ‘This person needs more help with care management or discharge planning.'

If we just automated and never looked at anything, we wouldn't have that lens through which to look at the member and make sure they get the best possible care. We are not just paying the bills. We are very serious about all the different levers we have to help members.

As a physician, you dealt with utilization management from the provider side. How did that experience influence your perspective as an insurance executive?

For about 15 years, I worked in an inner-city pediatric emergency department that was a level 1 trauma center, and I would see children come in and use the ER as their primary care provider — not a good idea. They would come in for rescue therapy and episodic care but, at the same time, were not getting the best end-to-end care because they never went to their primary care provider.

Take asthma, for example. I can't tell you how many children would come into the emergency department for rescue therapy with nebulizers and steroids, yet they were not on what we call a regulator drug.

When I came to managed care, I felt like this was a good opportunity to start thinking about ways we could work with members, providers and our data to understand how to flip some of those children from frequent flyers in the emergency department to well-managed children that are seeing primary care providers and, if necessary, specialists for their everyday asthma care.