Hospital and Physician Update
March – April 2023

A message from Jeniene Edwards, vice president of Utilization Management
Public Act 60 aims to improve prior authorization processes

Dr. James GrantPrior authorization continues to be a hot topic for health care providers and health plans alike.

According to the American Medical Association, physicians and their staff spend, on average, nearly two business days completing 41 prior authorizations per week. In fact, an AMA survey showed that 40% of physicians have staff who work exclusively on prior authorizations.

That’s why it’s good news for Michigan residents that the Michigan Insurance Code has been amended by Public Act 60 of 2022. The act, which goes into effect June 1, seeks to end unnecessary and costly care delays, and enhance provider decision-making, making it easier for health care providers to deliver care.

I’m pleased to report that Blue Cross Blue Shield of Michigan already meets a significant portion of the new regulatory requirements. Here are some examples of how we’re doing:

Requirements Blue Cross status
Prior authorization must be performed via a standard electronic transaction. Blue Cross meets this requirement through the e-referral system and vendor portals.
A list of all benefits subject to prior authorization must be published online. A full list of services subject to prior authorization is available on our provider portal.
Insurers will promote prior authorization opportunities, such as gold-carding, that are based on provider performance. Blue Cross meets this requirement and will continue to promote such opportunities.
Adverse determinations must be made by a licensed physician or pharmacist. Blue Cross meets this requirement, using licensed clinicians for all such decisions.
Urgent prior authorizations must be processed within 72 hours. Blue Cross and its vendors meet this timeline.
New or updated medical requirements must be made via provider portal 60 days in advance — and 45 days in advance for pharmacy requirements. Blue Cross will adjust the notification schedule to meet new requirements.

Blue Cross is also on track to meet all the other legislative requirements on or before statutory deadlines.

As part of our ongoing Blue Cross initiatives, we’re building on the requirements of Public Act 60 to transform prior authorization for all stakeholders. We’re currently looking to shift our approach to prior authorization from utilization management to providing clinical decision support. Our efforts are intended to:

  • Realize a seamless provider and member experience.
  • Incorporate provider feedback and increase engagement.
  • Make prior authorization easier and more transparent.
  • Enable enhanced coordination of care.

We’ve put together a multichannel communication plan to keep the provider community informed of evolving prior authorization processes and resources, especially as they relate to Act 60. For example, in a February Record article, we let providers know we’re ending voluntary prior authorization May 1. This will enable providers and Blue Cross to reduce unnecessary administrative costs and paperwork, improving the patient and provider experience.

We’ll be including additional information and updates in our newsletters and through Availity®, our provider portal, so stay tuned.

Availity is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.