Prior Authorization: Provider Perspectives Part 1

Prior Authorization: Provider Perspectives Part 1?

Imagine you are in Gulliver’s fantasy land of Brobdingnag, where King Golbasto's permission is required for every routine task, such as eating a meal! The king requires detailed documentation of how hungry you are, your weight, the location where you felt hungry, and where you will eat your meal. The details should also precisely include the number of items you want to eat from a national menu and defend your choice of meal based on your level of hunger.? Once your request is received, the king's aides will deliberate and get back to you within three days on whether the requested meal is justified based on the documented description of your hunger.? If your documentation includes the details of the urgency of the request, it will be prioritized and adjudicated within 24 hours!???

Ridiculous, right? This is exactly how healthcare providers feel about prior authorization! It is easy to sympathize with them, given that they navigate a process far more intricate than the customs of the mythical land.? Depending on hundreds of combinations of insurance carriers and health plans [1], providers must adapt their approach to prior authorization documentation for each service request [2]. This is akin to having hundreds of different versions of King Golbasto, each with his own whimsical twist to the documentation process! Worse, sometimes, different segments of service need multiple prior authorization approvals from different applicable plans! Unlike Brobdingnag residents having to make a very simple-minded meal choice, the providers need to precisely select the requested service from several thousand codes, many of which may require additional documentation. For example, if a physician orders a diagnostic test, he or she may need to provide the patient's medical history, lab results, and other supporting information that requires understanding of hundreds of thousands of additional codes!? In case of urgent and unanticipated care, the provider may have no choice but to perform the service and hope that it will be later retroactively approved. Declined services can be appealed and the appeal process may introduce additional delays.??

Adhering to prior authorization protocol is crucial because of its critical implications for payment and for avoidance of penalties for non-compliance. Prior authorization protocols have evolved for each specialty; each unique protocol requiring deep domain knowledge, specialized training, and certifications.? A diverse set of nomenclatures for standardizing diagnosis codes [3, 4], treatment codes [5], and a new set of job categories [6] have emerged in provider organizations to comply with prior authorization. This is comparable to Brobdingnagians learning an entirely new language and hiring an army of translators to submit their meal requests so they will get to eat their meals! Given the complexity of the prior authorization process and its constant churn, it is not surprising that an enormous amount of effort is spent by provider organizations in understanding and following prior authorization.?

(Provider’s perspective to be continued in the next newsletter with more details. Stay tuned…)?

References?

1. Forbes Health Advisor?
2. Addressing commercial health plan abuses ensure fair coverage patients providers?
3. ICD codes?
4. DSM codes?
5. CPT codes?
6. Clinical coder - Wikipedia

Read more from our Prior Authorization Series:

Episode 1: Exploring the Realities of Prior Authorization in Our Healthcare System

Episode 2: The Solution That Became the Problem: Unraveling the History and Transformation of Prior Authorization