Driving efficiences - Controlled prior approval for procedures of limited clinical value

What were the objectives? In order to gain prior approval for a procedure of limited clinical value (PLCV), commissioners had to undertake a lengthy negotiation with the provider which often resulted in considerable delays and a negative impact on patient experience and outcomes. It was determined that, for certain procedures, all parties would benefit from an automated prior approval process. Prior approvals would be granted according to criteria that were pre-agreed by the commissioner and provider, and the process would be tightly controlled by the CSU’s specialist Individual Funding Request team.

What did we deliver? We devised a secure web-based application that allowed providers to gain prior approvals quickly, based on pre-agreed rules for PLCVs. We ensured the application was intuitive, presenting providers with questionnaires that were quick and easy to complete and tailored to their organisation and the procedure in question. We gave commissioners administration rights so they could adapt the tool in terms of users, providers and procedures, and also to create their own questionnaires with custom logic. We developed a reporting mechanism that reconciled prior approvals with SUS (Secondary Uses Services) data, flagged records which fail the prior approval criteria for further analysis, and allowed multi-format data exports including PDF, CSV and Excel files. We implemented an automated challenge process that highlighted elements of care which failed the complex rule criteria for PLCV and did not correspond with commissioner given prior approvals.

How did we add value to the customer? The process and web-based application we developed drastically reduced the time required of commissioners and providers to handle PLCV requests and minimised the need for human intervention in the process, creating substantial efficiencies and financial savings. The intuitive application we created minimised the need for training or instruction, which minimised roll-out costs and error rates. The web-based reporting system we introduced eliminated the extremely resource-intensive manual reconciliation process that had previously been required, to determine whether a PLCV that had already been undertaken had received prior approval.

As this is a unique offering, we have since deployed the application to other CSU customers to streamline their own PLCV processes and maximise the benefit of our development to the NHS.

Customer Feedback “Since taking on this project, [the CSU’s] knowledge and experience have been invaluable to me. [They] understand the background to the project and have the ability to read complex clinical guidance and then present it in an accurate and clear manner. [They] also have extensive knowledge of hospital coding and charging and are able to provide advice on data analysis.” Lauren Pennington, Senior Commissioning Manager – Planned Care, North East Hampshire & Farnham CCG