SoonerCare prior authorization process to change

Posted on: 10/18/17

The Oklahoma Health Care Authority (OHCA) is in the middle of major changes to the SoonerCare (Medicaid) prior authorization process. Dr. Garth Splinter, OHCA deputy CEO, briefed the OHCA board on the changes at their Oct. 12 meeting.

More than 1,000 procedures associated with high costs or potential overutilization must be approved by the agency before these services are provided. OHCA outsourced their prior authorization (PA) work for imaging services to MedSolutions (later eviCore) in November 2010, adding speech, physical, and occupational therapies to the contract in July 2014. Radiation, cardiology, joint surgeries, spine surgeries, and pain management were added to the outsourced service in August 2015. Some of the PA processes were brought back in-house by OHCA in November 2016, and the entire PA contract expired July 1, 2017.  

OHCA planned to get new outsourcing proposals for the PA service, but budget and IT constraints forced changes, and the agency decided to keep these processes in-house. The net administrative expense saved from discontinuing the vendor contract has more than made up for a slight increase in claims expense, presumably from denying fewer PA requests.

Bringing all PA functions back in-house has caused some recent backlogs in approval, but OHCA says these are improving.

OHCA employees now use InterQual® desktop software in a manual determination of medical necessity. The agency plans to implement InterQual Connect® to their provider portal, to largely automate and accelerate the PA process. With InterQual Connect, providers will respond to relevant clinical questions relating to medical necessity, as determined by the software. This process may provide an immediate approval, or may result in further review.

In December, OHCA will start a three-month pilot program using InterQual Connect for prior authorization of hip and knee replacement surgeries. The rules and application of the medical necessity determinations will continue to evolve, as the agency tests new processing rules and applications for PA determinations.

Dental, pharmacy, and behavioral health services are preauthorized through other, separate processes.

In an Oct. 10 global message, OHCA notified providers of software requirements for the future InterQual Connect system. (Rick Snyder)