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Epic Outcomes

Automation Makes Preauthorization a Breeze

Carle and its health plan use Epic to automatically preapprove over 70% of imaging exams

Carle, a health system in Illinois, is using Epic to automate preauthorization for certain procedures. This automation saves patients time so they can get the care they need sooner and make sure that care is covered under their insurance. Carle estimates that this automation saves $120,000 annually by eliminating manual data entry.

When clinicians refer patients to have an expensive procedure, such as a CT scan or MRI imaging, payers require that the referral go through a review process called preauthorization to prevent duplicative or unnecessary testing. Health systems can reduce denials by using clinical decision support tools that evaluate data available in Epic and provide feedback on the appropriateness of the procedure before preauthorization is requested.

Carle and its health plan, Health Alliance, have further automated by removing redundancy between clinical review processes. When a procedure has already been deemed clinically appropriate, it needs to be evaluated only for benefits coverage and is sent automatically from Epic. Carle and Health Alliance now preapprove over 70% of imaging exams that are scored this way.

“Manually managing and responding to authorization requests is a time-consuming, multi-step process that can leave room for error,” said Tammy Hoult, Carle’s senior IT project manager. “Instead, we’ve automated that process to ensure that our patients and members receive the care that they need in a timely manner.”

Epic community members can learn more about this feature on the UserWeb and review Carle’s XGM presentation slides and audio.