Looking Beyond Immediate Compliance: Optimizing Prior Authorization with Salesforce Health Cloud

Today, prior authorization process automation is a payer aspiration; in the future, it may become an expectation. In early December 2022, the Centers for Medicare and Medicaid Services (CMS) released a proposal that, if approved, would compel certain payers to adopt electronic prior authorization solutions by 2026. While this mandate has yet to be passed, it poses a potentially enormous compliance hurdle for payers — and, we would argue, a crucial accelerator for payer innovation.

This white paper will unpack the proposed legislation and its immediate challenges (e.g., interoperability, data- sharing, approval turnaround, denial contextualization, process management, reporting, etc.). Then, we will:

• Review prior authorization solutions currently available to payers, and what organizations can do to prepare for a digital-forward future
• Reflect on promising projects (e.g., the DaVinci project) that may streamline prior authorization activities in the future
• Make a case for why digitalizing crucial processes — including and beyond prior authorization — should be both a short-term imperative and long-term priority for payers
• Consider how payers might leverage comprehensive, scalable platforms like Salesforce Health Cloud to flexibly adapt to change while improving their operational performance