Headaches and Heartaches Associated with Prior Authorization (PA) in Medicine Today

Health insurance companies use #priorauthorization to verify that a certain drug, procedure, or treatment is medically necessary before it is done or prescribed. It is the process of getting approval from your health insurance company (not your doctor) to obtain a prescription or treatment.

Even before the COVID-19 pandemic, the PA process had become the headache and heartache of doctors and patients. Physicians say that health insurers’ authorization requirements, which can delay the use of drugs and treatments by days or weeks, are not just a small irritant. They can subject patients to serious harm. They can even be life-threatening.

Five (5) Prior Authorization Challenges To Consider

(1) Time-Consuming for Doctors

There are multiple steps that a physician has to follow to complete prior authorizations. This can involve securing the correct form, fill it out with the required information, submitting the form to the plan, etc. In particular, holding time is long when trying to reach a customer service representative in the insurance company, with hold times averaging 20 minutes or more. Many physicians will tell you that the overall process can take 30-45 minutes for each PA submission.

(2) Costly for Medical Practices

Although PA has been an issue among physicians for many years, little is known about the cost, either to individual practices or the healthcare system as a whole. One study estimated that, on average, PA requests consumed about 20 hours a week per #medicalpractice: one hour of the doctor’s time, nearly six hours of clerical time, plus 13 hours of nurses’ time. A study by Health Affairs further revealed that practices spent an average of $68,274 per physician per year interacting with health plans when the time is converted to dollars.

(3) The Process Problem

Failure to obtain proper authorizations can have a drastic effect on the practice income. No authorization means no payment. Insurers won’t pay for procedures if the correct prior authorization isn’t received, and most contracts restrict you from billing the patient. PA denials result in lost revenue, declines in provider and patient satisfaction, and delays in patient care.

The chart below demonstrates this and shows how much revenue is lost due to authorization.

Prior Authorization Predicament

Denied claims create the need for manual intervention; this increases practice costs and administrative transaction costs (just under $14 per transaction).

A common problem with many busy practices is that many #claimdenials sit unworked since denials are usually the most difficult and time-consuming work for billing staff. PA requires multiple letters with supporting documentation and multiple telephone conversations. Consequently, PA costs are expensive, administratively daunting, and unsustainable for most primary care providers.

(4) Patient Delay

The real impact of PA is often felt by patients who are delayed in getting their medication or treatment. As a patient, PA problems can create a huge interruption; they have to determine whether the process is stalled out with the doctor, the insurance company, or the pharmacy.

During this time, patients are unable to start treatment. These long wait times harm patient experience and patient care.

(5) Process Management

The management of PA can sometimes be difficult to manage as the requirements can vary widely from one payer to another. Each of them also has a different process for submitting PA requests.

Even when the practice has provided a request in a timely way, the insurer may still end up not paying for the prescribed medication or treatment. Unfortunately, claims with prior authorizations are denied more often than you might think.

What Can Be Done to Improve the Prior Authorization Process?

Although prior authorization is an unavoidable step in many practices, the current process is all too often manual. It involves prescribers, payers, pharmacists, and patients in a cumbersome flow of information that may result in delays in treatment and dissatisfaction for all. As a result, many implement electronic prior authorization solutions to address common issues with the approvals process.

Tips That Speed Up The Prior Authorization Process

• Create a master list of procedures that require authorizations
• Document denial reasons
• Sign up for payer newsletters
• Designate prior authorization responsibilities to the same staff member(s)
• Create a quick reference guide of your payer contacts
• Be methodical about working authorizations

Summary

Vendors, healthcare professionals, payers, patients, and others should work cooperatively to create a prior authorization process that is as seamless and burden free as possible. When communicating clinical information, healthcare professionals and payers should be able to leverage technology and have ready access to clinical guidelines and payer rules in order to request and execute prior authorization for any service required for patients. #priorauthorization #medicalpractice #claimdenials

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