[adolph]

Part of the problem is informational. Payors, which may include those backed by nonprofit (like BCBS) and government (CMS), are tasked with reducing un-necessary and duplicative services. This is a critical duty in bending the high cost of healthcare.

Payors identify specific procedures or treatments which represent things they want more information about before they commit to paying for it. It is difficult work on the healthcare provider side to understand what requires pre-auth and provide the payor's decisional information. There is a HL7 group that is working on the problem, the DaVinci Project:

Interoperability challenges have limited many stakeholders in the healthcare community from achieving better care at lower cost. The dual challenges of data standardization and easy information access are compromising the ability of both payers and providers to create efficient care delivery solutions and effective care management models. The goal of the Da Vinci project is to help payers and providers to positively impact clinical, quality, cost and care management outcomes.

http://www.hl7.org/about/davinci/index.cfm?ref=common