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BlueShield Lifts Preauthorization Requirements for Members and Physicians

Streamlines access to care, empowers health care providers, improves member satisfaction and quality

February 01, 2017

In 2017, the region’s leading health plan, BlueShield of Northeastern New York has announced significant changes that will allow members more efficient access to care as directed by their physicians and other health care providers without having to wait for approval from the health plan, a process known as “Preauthorization.”

In response to significant feedback from members and physicians, effective February 1, 2017, over 200 services across 20 medical protocols will no longer require preauthorization. The designated set of services will be covered in accordance with a member’s specific benefits. This shift will most positively impact primary care physicians, home health, and durable medical equipment providers and their BlueShield patients.

Preauthorization is a process used by health insurance companies to determine if a prescribed procedure, service, or medication is medically necessary and covered under a member’s benefits.

Although the decision to significantly reduce preauthorization requirements took several months of data and trend analysis, the health plan’s efforts and announcement align and coincide with a recent call by the American Hospital Association and American Medical Association to reduce prior authorizations in the interest of efficiency and patient care. 

Vice President, Regional Executive and Medical Director, Dr. Kirk Panneton noted, “I was a full-time practicing pediatrician before accepting a senior leadership role at BlueShield a few years ago.  Since arriving, our team has made purposeful strides to streamline policies and procedures that get in the way of doctors caring for their patients.  Today’s announcement puts our physicians more squarely in the driver’s seat regarding medical decision making and the care they provide to our members.”

Consistent with a national shift away from fee-for-service payment models, BlueShield has been at the forefront of creating value-based partnerships with the local health care community. These programs drive more efficient and higher quality care, which decrease the traditional reliance on preauthorization policies.

In addition, BlueShield’s participating providers are expected to continue to adhere to the plan’s clinical practice guidelines, assuring safe, effective and appropriate care.

“At BlueShield, we understand the administrative demand on local physicians and health system team members. We have listened carefully to the physician voice in our community.  In doing so, we have put providers first and taken meaningful action to streamlining processes  so they can focus on what they do best, delivering accessible, high quality care to our members,” added Panneton.

As part of this initiative, BlueShield has implemented an ongoing review process to measure the effectiveness and appropriateness of preauthorization requirements moving forward. Information on the change, including a specific list of impacted procedural codes has been communicated with providers.