Automating Medical Necessity for Prior Authorization, Sponsored by MCG Health

This 1-hour webinar will address critical challenges healthcare organizations face when automating the “medical necessity review” aspect of prior authorization using interoperable standards and terminologies. MCG Health experts will share various strategies deployed by real clients to address this challenge and successfully automate medical necessity review.

Learning Objectives:

• Describe the different types of payer criteria used for medical necessity
• Identify the opportunities to automate medical necessity criteria
• Examine the tactics required to codify medical necessity criteria
• Explore one use case to understand how MCG successfully automated the review of medical necessity

About the Speakers:

Rajesh “Raj” Godavarthi, Associate Vice President of Technology and Interoperability

Rajesh “Raj” Godavarthi is MCG Health’s Associate Vice President of Technology and Interoperability. Mr. Godavarthi has been with MCG since 2002, and he oversees a team of software developers and architects that are building the key interoperability solutions that are outlined in MCG’s roadmap for the future. His team also helps develop, enhance, and maintain MCG’s evidence-based clinical decision support software currently used by nine of the largest U.S. health plans and nearly 2,600 hospitals.

In addition, Mr. Godavarthi is MCG’s primary representative in the HL7 Da Vinci Project. MCG has been an Associate Member of this consortium since 2019, and Mr. Godavarthi has led our efforts to support industry stakeholders developing new HL7^® FHIR^® standards which will allow for improved interoperability and communication between payers and providers. In September 2021, Mr. Godavarthi was named the co-lead for the HL7^® Da Vinci Project’s burden reduction use cases in prior auth support (PAS), coverage requirement discovery (CRD), and documentation templates and rules (DTR). In May 2022, he was recognized as one of the 2021 Da Vinci Community Champions. These individuals are publicly acknowledged for making significant contributions to advancing implementation guide use.

In July 2021, he became a member of the WEDI Prior Authorization Subworkgroup. WEDI (Workgroup for Electronic Data Interchange) is a formal advisor to the U.S. Secretary of Health and Human Services (HHS). They are a leading authority on the use of health IT to efficiently improve health information exchange, enhance care quality, and reduce costs.

In December 2021, Mr. Godavarthi was elected to the WEDI Board of Directors, and he was subsequently appointed to serve a 3-year term on the Office of the National Coordinator for Health Information Technology (ONC)’s Health Information Technology Advisory Committee (HITAC).

In July 2022, Mr. Godavarthi was recognized by the HL7^® Da Vinci Project as one of eight healthcare technology experts who are 2021 Da Vinci Community Champions.

Lisa Mahoney, Manager of Clinical Informatics

Lisa Mahoney is a Manager of Clinical Informatics at MCG Health. Ms. Mahoney has been with MCG since 2019 and collaborates with a team of physician informaticists to create rule-based algorithms for capturing clinical data from the patient’s EHR to support admission and utilization-based activities within MCG’s products. Her team develops and maintains a growing library of MCG’s evidence-based clinical decision support by developing novel approaches toward meeting the needs of its growing customer base.

Prior to MCG, Ms. Mahoney worked at other Hearst Health organizations including Zynx and an early prior authorization startup. Ms. Mahoney is a registered pharmacist, who graduated from Massachusetts College of Pharmacy and Allied Health Science. After spending several years in clinical practice within Boston area hospitals, Ms. Mahoney transitioned into the rapidly expanding field of informatics, working with Partner’s Healthcare in Boston within the Center for Informatics Research and Development.