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Blue Shield of California is partnering with tech company Salesforce to give physicians and patients prior authorization answers in actual time, instead of days.
The aim is to streamline the prior authorization process, while at the same time making it more transparent.
The platform solution will be constructed on the Salesforce Health Cloud and link members to individualized health support by automatically notifying care teams of prior authorization inquiries.
In a statement, Blue Shield explained that it will use Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) standards to produce technology that will streamline 20-plus disparate systems that exist now into one process that merges with physicians’ current workflow.
Generated by physicians, the platform solution searches a patient’s electronic health record for pertinent clinical information and compiles it into a pre-populated electronic form. As a result, physicians will have the ability to submit requests from their systems immediately without using a fax machine.
In addition, members will be given answers during their medical appointments. Medical directors and licensed clinicians would be responsible for making modifications or denials.
If a clinical consultation is necessary, physicians will get a message in real time informing them what is needed to finish the authorization and the options required to start a peer-to-peer consultation. Currently, that process can take days.
Meanwhile, Blue Shield members get status updates via their member app.
The new platform solution will work parallel to Care Connect, Blue Shield’s care management system, by creating a clinical infrastructure that changes the focus from the moment of medical requirement to continuous, preventive care and wellness.
Down the road, a prior authorization request will automatically alert the health plan’s team that a member may need new or additional health support.
Testing on the prior authorization platform is scheduled to begin in early 2025 with limited rollout later in year. The company anticipates “near real-time prior authorization” to be available in Jan. 2026, with additional capabilities after that.
“Prior authorization was never meant to be a barrier or a burden. As a health plan, it’s our responsibility to ensure safe, evidence-based, high-value care for our members, and we know it can be an easier process for everyone,” Paul Markovich, chief executive officer of Blue Shield of California, in a statement.
“That’s why we are taking the bold step to make it as easy as using your credit card, while enabling more coordinated, personalized support for members. It is time for the industry to let go of fax machines.”
THE LARGER TREND
In April, IQVIA expanded its partnership with Salesforce to help increase its customer-engagement platform for the life sciences industry.
The two companies will also utilize IQVIA’s Orchestrated Customer Engagement Platform, its data and analytics and Salesforce’s CRM to develop the Salesforce Life Sciences Cloud for customer engagement.
In March, Salesforce launched a new healthcare AI assistant, Einstein Copilot, which delivers responses based on a healthcare organization’s private data.
The AI assistant is designed to trigger workflows that forward referrals, book appointments and other administrative jobs. The company also released Assessment Generation and Data Cloud for Health, which allows caregivers to automate and streamline clinical summaries, personalize communication and tailor patient assessments quicker.
Last year, Blue Shield of California unveiled a multiyear cloud-development plan with Microsoft to offer its members an integrated data hub.
The Experience Cube runs on Microsoft’s Azure cloud platform and utilizes Azure’s analytics and storage capabilities to tie together near real-time member, provider and payer data. The aim is to create more personalized services for members and drive insights for providers.
In 2020, Blue Shield of California waived out-of-pocket costs for all commercial plan members using Teladoc Health’s services until May 31 of that year. The waiver included individual and family plans as well as those sponsored by an employee.
At the time, Blue Shield had already removed co-pays and coinsurance payments for its Trio, Tandem and Medicare Advantage plans and for its Blue Shield of California Promise Health Plan.
