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The initiative is part of a broader strategy to ensure Capital members receive safe, high-quality, and cost-effective care more quickly.

When it comes to staying healthy, achieving the best outcomes while managing costs can be challenging.

On one hand, the U.S. wastes an estimated $75.7 billion to $101.2 billion annually on overtreatment and unnecessary medical care, according to a study in the Journal of the American Medical Association. On the other hand, efforts to manage these costs through preauthorizations – reviewing certain treatments and procedures to confirm they are medically necessary prior to receiving services – have been criticized for creating treatment delays for patients and administrative burdens for providers.

In an ongoing effort to improve the safety, speed, and quality of care patients receive, Capital Blue Cross has removed preauthorization requirements on more than 700 medical services, including about 80% of home health and 95% of outpatient therapy/rehabilitative services.

Eliminating preauthorizations benefits patients, providers

The change means common services such as outpatient physical therapy, occupational therapy, and respiratory therapy can now be done without prior approval from Capital. This helps provide:

Broader Access to Care:

Allowing treatments and services to be done without the need for preauthorization helps healthcare providers deliver more services more quickly.

Improved Member Experience:

Simplifying the approval process helps reduce the administrative burden on both members and healthcare providers, ensuring a smoother and more efficient healthcare journey.

Enhanced Provider Collaboration:

Reducing the need for preauthorization for certain treatments helps foster a more collaborative relationship with healthcare providers, enabling them to focus more on patient care and less on administrative tasks.

Capital’s scaling back on preauthorizations came about as part of a year-long review and mirrors a national trend.

This year alone, at least 10 states passed legislation to make the process of obtaining preauthorization faster and more efficient. Pennsylvania passed legislation that aimed to streamline preauthorization in 2022.

Dr. Jeremy Wigginton, Capital’s Chief Medical Officer, said Capital’s initiative to scale back preauthorization goes beyond what Pennsylvania’s legislation requires.

“This initiative is part of our broader strategy to ensure Capital members receive safe, high-quality, and cost-effective care more quickly,” Dr. Wigginton said. “We are confident that these changes will lead to better health outcomes and higher satisfaction rates for both members and healthcare providers.”

“This reduction in preauthorization is just the beginning of our efforts to improve healthcare delivery and ensure patients receive the best continuity of care possible.”

In evaluating whether preauthorization might be needed for a medical procedure, Capital reviews usage rates on medical services and consults with medical professionals to stay current on standards of care, Dr. Wigginton said. As medical guidelines change, Capital will continue to evaluate and adjust accordingly, he added.

The ultimate goal, Dr. Wigginton said, is “to ensure Capital is always evolving to provide coverage for a more efficient, effective, and patient-centered system of care.”

You can find more useful articles at https://thinkcapitalbluecross.com/

Information provided to TVL by:
JERRY REIMENSCHNEIDER
Senior Public Relations Specialist | Brand & Market Strategy
https://www.capbluecross.com/