There is no doubt that prior authorizations are one of the greatest frustrations in every clinical practice. Physicians blame prior authorization of the delay and prevention of needed treatment and care for a patient. Prior authorizations are there to prevent unnecessary spending but pose as another administrative headache. It refers to the strategy where the payers control the cost and ensure the necessity of the advised medical or treatment for the patient. However, it tends to delay the services. Before we start discussing the strategies, it is important to know how prior authorizations work to have a better grasp on how to alleviate the burden.
How Prior Authorizations Work?
Prior authorization serves as a requirement for the doctor to acquire approval from your healthcare insurance provider before they can prescribe a treatment, a specific medication, or an operation. The patient will be left to shoulder the bill for the medication or operation if their health insurance provider rejects their claim and doesn’t give the prior approval needed. Here are more reasons why healthcare insurance providers require prior authorization:
- To check the necessity of the treatment or medication
- To determine if the request of the treatment or medication follows the latest recommendation for the patient
- To ensure the most economical treatment and medication is being given to the patient. For example, if the doctor prescribes a medication called Drug A that is expensive, the healthcare insurance provider will wonder why Drug B, which is the cheaper alternative won’t work. This will then lead to the rejection of the prior authorization request.
- To ensure that there is no duplication of service, especially for patients that have multiple specialists and physicians involved in their care. For example, if the primary healthcare provider requested a CT scan two weeks before your neurologist requested another CT scan. The healthcare insurance provider won’t release a pre-authorization not unless the primary healthcare provider views the CT scan two weeks before the new intended request and will vouch for the necessity for another.
- To confirm the effectiveness of the on-going treatment. For example, the patient is in physical therapy for three months and their physician is asking for another authorization to extend it for another three months. The healthcare insurance provider then will need supporting documents about whether or not the treatment is helping the patient. If the treatment is not making any progress or is making it worse for the patient, then the request will be denied.
Furthermore, prior authorizations can be viewed as rationing and rationalizing healthcare, may it be treatment or medication, for their beneficiaries. This is to ration access for expensive treatments and medications. This will ensure the appropriate treatment and medications will be given only to the right people. Making healthcare cost-effective, appropriate, necessary, and safe for all beneficiaries.
Despite that goal, prior authorizations are controversial for being an administrative burden and obstacle delaying treatments for patients who need the treatments as soon as possible. The affected patients are those who need extensive treatment and expensive medication due to a pre-existing, complex, or dire condition. The speed in processing prior authorization requests can heavily impact the state and condition of the patient, slowing their progress, and burdening the practice with additional administrative tasks to further carry.
Medical Practices and healthcare providers are not entirely helpless in dealing with prior authorizations. There are a lot of ways on how they can ease the burden, efficiently helping more of their patients in return. Read further to learn the strategies that you can utilize to reduce the burden of prior authorizations in your practice:
- Dedicated Staff. Have a specific staff dedicated to dealing with prior authorization requests. The staff will serve as a liaison for healthcare insurance providers. They will be able to breeze through the processes easily as they will become “experts” in dealing with it for furthermore.
- Utilize the Right Technology. Technology can greatly reduce time spent on prior authorizations. Healthcare insurance providers offer online prior authorization processes with formulary list integration to your EHR
- Ensure Proper Documentation. Proper documentation ensures strong reasoning and evidence to back up your chosen treatment and/or medication for your patient. Strengthen your case and familiarize yourself with generic options together with the documentation to defend your decision.
- Stock on Forms. Prepopulating the necessary forms per healthcare insurance provider can save you a lot of time. The prior authorization staff can just fill-up the form immediately when in need.
- Build and Strengthen Relationships. Knowing who to talk in healthcare insurance providers can go a long way. They might give tips and ideas in case problems or confusing complex processes arises.
- Streamline the Process. Take time to document how process work per healthcare insurance provider’s company. It may vary per provider, so it will lessen the frustrations for the staff, especially when they are not that familiar with it yet.
- Present Plans to your Patients. Sometimes, it is better to stick to an insurer’s formulary to acquire good merits and trach records to them.
Additional tips from the American Academy of Family Physicians in reducing your burden from Prior Authorization processes:
- Familiarize on equally safe and effective but cheaper alternatives to any high-cost drugs you prescribe. This way, you won’t have to go through the prior authorization process.
- Have a master list of medications and procedures that require prior authorization, broken down per healthcare insurance provider. Your prior authorization staff can also program your electronic health record to alert you when you order something that requires prior authorization in reference to the lists.
- Insurers are likely to require prior authorization for orders outside those recommendations from evidence-based guidelines
- Prescribe generic medications when possible. These usually do not require prior authorization.
- You can also educate your patients about prior authorization and coverage limitations. This can reduce patients’ anger and frustrations toward you for treatment delays or refusals and can help direct their complaints to their insurer, which could bring about a change in insurer policies.
- Spend more time on documentation. Specifically, do this when ordering things you know do not follow the standard guidelines.
- Systemize the process by creating pre-populated forms. If possible, use the insurer’s forms, listing codes, diagnoses, and other information the insurer typically requires to process prior authorization.
- Designate one or more staff members to handle all prior authorization requests. This can free up the physician’s time and allow the designated staff to become more knowledgeable and efficient.
- Use technology whenever possible. This includes filling out prior authorization requests online as opposed to over the phone.
- Push insurers to meet their deadlines for turning around prior authorization requests.
- If denied, use the appeals process. Make sure to keep track of appeals and how long until an insurer must make a decision.
- Take advantage of a payer’s peer-to-peer process. Speaking to the insurer’s medical director or another physician available to speak with physicians about prior authorization issues can clear up problems much faster.
- When all else fails, fight. Some physicians send a form letter defending their use of a particular medication or pointing out the dangers of changing patient drug regimens, while others threaten to send the insurer a bill for their time.
Prior Authorizations are indeed a burden. If you need assistance in your prior authorization processes and other administrative tasks, DrCatalyst is delighted to help. Our expertly-trained and experienced clinical staff will provide you with administrative support that allows you to focus more on patients, not paperwork. Schedule a free consultation today!