Point32Health Services Inc., the parent company of Harvard Pilgrim Health Care and Tufts Health Plan, recently updated its prior authorization requirements for home health care services for members in its commercial plans. Kate Skouteris, vice president of regional commercial markets for Point32Health, spoke with Providence Business News about the updated requirements.
PBN: How did Point32Health change its prior authorization requirements?
SKOUTERIS: At Point32Health, we are committed to continuously evaluating ways to streamline the delivery of high-quality care and effectively support our provider partners by minimizing administrative burden. As a result, our clinical team routinely reviews prior authorization requirements. That is why in April of this year, we announced that Point32Health would be updating our prior authorization requirements for home health care services for members in our commercial plans. This change removed the requirement for utilization management for the first 30 days after a member is discharged from a hospital.
Before this change, skilled services provided in the home – physical therapy, occupational therapy and speech-language pathology services; social work visits; home health aides; skilled nursing; nutritional counseling – required prior authorization after the initial evaluation for Harvard Pilgrim and Tufts Health Plan plans. Instead, these services now require notification for the first 30 days of service – after the initial 30 days, prior authorization is required for continuation of coverage.
PBN: Why did Point32Health change these requirements?
SKOUTERIS: While prior authorizations are an important tool in containing costs while ensuring our members receive quality care, they can come with an administrative burden for both providers and our members.
Recent studies have shown that physicians report the top driver of burnout is too many administrative tasks. By continuously reviewing prior authorization requirements and eliminating them when there is an opportunity and need to do so, we hope to minimize this burden, improve turnaround times and better facilitate the coordination of care for members.
This effort continues to be part of a larger review we have been conducting to seek new and innovative ways to partner more closely with the provider community, while doing all we can to contain costs, increase efficiencies and make health care more transparent, affordable and accessible.
When looking at our competitors, Point32Health already has fewer prior authorization requirements, and we will continue to evaluate the need for removing prior authorizations from medical services and drugs that have a low denial rate and where clinical oversight is not strictly necessary given standard provider practice.
We expect to remove additional requirements in the coming months while remaining focused on the best experience for our members and providers.
PBN: How have you seen these changes affect the company and patient care?
SKOUTERIS: From a patient care perspective, we are proud to say that the removal of these prior authorization requirements allows for our members to have a simpler, smarter and more seamless experience when accessing their health care, while balancing the cost and quality of the care. Patients no longer have to wait for these approvals from Point32Health and their provider when seeking access to the care they need, leading to improved turnaround times, better coordination of care and more satisfied patients and providers.
PBN: How is Point32Health partnering with providers?
SKOUTERIS: One way we provide improved care for our members is through innovative provider partnerships. An example of that is our collaboration with Women & Infants Hospital and Meals on Wheels of Rhode Island. This program utilizes clinical social workers at the hospital to support expecting mothers with high-risk prenatal medical conditions, such as gestational diabetes, and those whose income may be a barrier to consistent, nutritious meals. The initiative successfully provides healthy, no-cost, home-delivered meals to help close the gap in health disparities and improve outcomes for pregnant and postpartum mothers.
PBN: In what ways is Point32Health looking to control costs, and how does this affect patient’s access to health care?
SKOUTERIS: At Point32Health, we recognize the need to establish integrated prior authorization workflows with provider partners to reduce abrasion and improve efficiency. This is paramount to also controlling costs. When prior authorizations are appropriately utilized, there is a demonstrated benefit of avoiding medically unnecessary care and containing health care costs.
However, it is clear that prior authorization is labor intensive and burdensome for providers and payers, causing dissatisfaction. The need for change is evident and Point32Health is dedicated to being a leader in prior authorization reform, including embracing any upcoming state and federal regulations and exploring opportunities to bring automation to the prior authorization process.
We believe that everyone should have equitable access to affordable, high-quality health care, regardless of their age, race, ethnicity, socioeconomic status, orientation, gender identity or ability. Our dedication to ensuring our members receive high-quality health care is well balanced with cost-saving measures to allow our members to have access to a wide network of health care providers and facilities. We focus on data to develop new programs and services for our members and provider community, and strive to advance quality, equity and maintain affordability.
Katie Castellani is a PBN staff writer. You may contact her at Castellani@PBN.com.
