Dr. John Svirbely's blog post - Modelling Preauthorization Part I: The Problem
Dr. John Svirbely, MD
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Modelling Preauthorization Part I

The Problem

By Dr. John Svirbely, MD

Read Time: 3 Minutes

Preauthorization is the process by which a Payer determines whether it will provide coverage for a future service (drug, imaging study, surgery, etc). Each Payer provides a list of the requirements for each condition that must be met to obtain approval. The whole process is simple in theory, but it has proven to be complex in practice.

Because of perceived problems around preauthorization, the Centers for Medicare and Medicaid Services (CMS) has issued a mandate (CMS-0057) that must be met in the next few years by Providers and Payers. The goal is to improve patient care by removing some of the barriers that Patients experience in their care.

If It Were an Ideal World

In theory preauthorization should not be a problem. There are 4 core validations to be made:

1

Does the Patient have a contraindication, making the request unsuitable?

2

Does the Patient have an approved indication?

3

Is the indication significant (based on severity, stage or some other measure)?

4

Have alternative therapies that may be cheaper or less hazardous been tried?

As a rule, this can be stated as: IF the Patient does not have a contraindication AND if the Patient has an approved indication AND if the condition is significant enough AND if other options have failed, THEN the request should be approved ELSE denied.

This can be depicted in BPMN as:

BPMN Template for Pre-Authorization

This is all very straightforward. So why are there perceived problems?

Nothing Is Perfect

Unfortunately, assumptions about an ideal world tend to fail in the real world. Failures may be due to a range of factors, such as:

Potential Patient-related issues:

Potential Provider related issues:

Potential Payer related issues:

While denial of a request can always be appealed, the whole process of responding to a denial is a major pain point for Providers. Failing to appeal may mean that a Patient does not get the care that the Provider believes is necessary. On the other hand, appealing a denial can be a long and painful experience. The denial process is not standardized between Payers and can appear to be somewhat arbitrary. Providers often:

A Provider can always refer denials to a third party to manage, but the costs of doing so may become an issue when reimbursements are low. This leaves many Providers feeling trapped by a system that does not listen to them.

What Might Be an Effective Solution?

To solve these problems there is a need for:

Whether CMS will be able to provide an effective solution will depend on several factors, including any unexpected consequences of the mandates. The goals are commendable, and now it is up to the stakeholders to work together to make it a success. In the next part we will discuss how BPM+ can provide solutions to these problems.

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Dr. John Svirbely's blog post - Healthcare Orchestration versus Healthcare Choreography: Handling Interactions Between Processes
Dr. John Svirbely, MD
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Healthcare Orchestration versus Healthcare Choreography

Handling Interactions Between Processes

By Dr. John Svirbely, MD

Read Time: 3 Minutes

Modeling of a clinical practice guideline or care plan may require multiple processes assigned to different actor pools. Some of these processes may need to interact with others in a dynamic fashion. How are these interactions managed in an unpredictable world?

Some interactions may be relatively simple, such as a conditional process that is triggered by an event. However, others may be much more complex, requiring multiple exchanges between the interacting processes. For these situations we can make use of either orchestration or choreography.

What is Orchestration?

In an orchestra there is a conductor exerts central control, directing various musicians playing different instruments according to a composition. With process orchestration, one or more processes acts as the controller (“conductor”), directing other processes (“players”), according to some prescriptive flow (“composition”).

Orchestration is a stateful activity in that it needs to remember previous interactions, to maintain a record of the current state, and to know what still needs to be done. BPMN and CMMN are both stateful and can be used to orchestrate.

Examples of orchestration in healthcare include the execution of a care plan, chronic disease management or the management of a cancer patient by a multidisciplinary care team.

What is Choreography?

In choreography there is no central control. Interactions are more of a negotiation between participants with certain rules of engagement in place. Participants are typically acting independently, with choreography capturing the communications between the participant. In BPMN choreography involves the use of choreography tasks. A choreography task can stand alone or can be connected with other tasks into a choreography process.

A choreography task icon

Examples of choreography include scheduling an examination with a patient, making a referral with a consultant, or obtaining preauthorization from an insurance company.

Comparison of Orchestration versus Choreography

Both orchestration and choreography have their pros and cons. The choice of using one or the other depends on your needs and goals.

Feature
Orchestration
Choreography
Centralized control
Yes
No
Coupling
Tight
Loose
Complexity
Simple
Complex
Cost of maintenance
High
Low
Action
Prescriptive
Procedural contract between interacting participants
Troubleshooting
Easy, often with a single point of failure
Complex

Incorporating these into a notional model may be simple. However, actually getting them to work properly in an automated process can be challenging, especially for novices.

For healthcare a common approach is to use orchestration implemented with BPMN. These orchestrations may need to extend beyond interactions between BPMN processes and pools. They may also need to control data acquisition and connections to outside systems impacting the patient’s care, such as generative AI.

Orchestration in a Healthcare Solution

Conclusion

When dealing with different processes or actor pools that need to interact, modelers use orchestration or choreography. The particular choice depends upon the conditions and the goals. Having choices allows for flexibility in designing a solution that can serve both current needs as well as evolve over time as conditions change.

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