Prior authorization (PA) is the bureaucratic gatekeeper standing in the way of effective care delivery. At a time when the healthcare system strives for optimum resource utilization to stay solvent, the time-intensive PA process complicates decision-making and threatens fiscal health.
The 2023 AMA prior authorization survey reports that physicians invest nearly 12 hours per week on PAs, underscoring the heavy administrative burden involved. Even more concerning, 94% of physicians agree that prior authorization delays access to necessary care, and 1 in 4 physicians attest that it has led to severe adverse events.
The intent behind prior authorization was to mitigate wasteful and excessive spending. However, it often acts as a barrier that delays necessary medical treatments, exacerbates administrative burden, strains patient-provider relationships, and leads to higher overall utilization of healthcare resources. Let's explore practical techniques to streamline the prior authorization process and alleviate administrative burdens.
Over 80% of physicians report that there has been an upward tick in the number of prior authorizations required for prescription medications and medical services. While the AMA advocates for reforming the prior authorization process, here are some practical tips to reduce the burden of prior authorizations in your private practice.
Compile a comprehensive list of medications and procedures frequently requiring prior authorization, categorized by insurance provider. Tweak your electronic health record (EHR) system to flag prescriptions or orders needing PA. This ensures that the next time you prescribe a brand-name medication that requires PA with a specific insurer, your EHR alerts you promptly.
Before prescribing a high-cost medication, consider generic or less expensive brand-name alternatives that offer the same clinical benefits. This proactive approach can help you avoid the prior authorization work altogether. For instance, choosing a generic version of a cholesterol medication rather than a brand-name option can provide equivalent therapeutic benefits and is less likely to require PA.
Furthermore, insurers typically require PA for treatments that deviate from established guidelines. Adhering to these guidelines reduces the chances of needing PA for your prescriptions and procedures.
Prior authorization rules can differ between insurance companies, making navigation challenging. Assigning a dedicated staff member to manage PAs saves physicians valuable time and ensures that PAs are handled efficiently. This team member can stay informed by regularly reviewing payer newsletters, bulletins, and websites for any updates to the PA process, mastering efficient management.
It's important to note that hiring a full-time PA specialist isn't always necessary. With appropriate training, existing team members like coders, billers, medical assistants, or even front desk staff can handle these tasks effectively.
Delays in prior authorizations usually stem from incomplete information. Develop templates that include pre-filled details like necessary codes, diagnoses, and other payor requirements to process a prior authorization efficiently. It's best to mirror the insurer’s forms to stay compliant.
Moreover, these forms should be regularly updated to align with changes in the payor requirements. This keeps everything running smoothly and helps you get approvals faster.
Robust documentation is crucial for expediting the prior authorization process. Ensure comprehensive documentation that validates the medical necessity of a treatment. Support your case with compelling reasoning and evidence on why you choose it over generic options or standard treatments available. This is particularly important for treatments that diverge from standard guidelines.
Furthermore, detailed documentation enables other staff members to handle most of the paperwork, leaving more time for patient care.
Electronic prior authorizations (ePA) can significantly speed up the PA process and improve efficiency. Instead of dealing with faxes, submit requests electronically and use technology — like a web portal or your EHR system — to upload supporting documentation. Moreover, integrating ePA into your existing EHR system enhances efficiency by eliminating the need for manual data entry into the proprietary health plan portals. This integration makes it easier and faster to obtain approvals.
Furthermore, improve prior auth efficiency with the following EHR tweaks:
Streamline your prior authorization process and reduce administrative burden by leveraging Glenwood's ePA technology. GlaceEMR enables you to submit prior authorization requests easily, speeding up approvals, ensuring timely medication delivery, and enhancing overall patient care.
Nearly 78% of physicians acknowledge that delays in prior authorization can lead patients to consider abandoning medical treatment. These delays often contribute to frustration among patients, which may inadvertently affect their perception of their healthcare provider. Help your patients understand that the insurance company may need additional information to approve their medication, which may lead to delays.
Proactive and transparent communication with patients empowers providers to effectively manage expectations, prevent treatment abandonment, and mitigate any potential animosity toward the physician. It also fosters a trusting relationship between patients and healthcare providers, ensuring patients feel informed and supported throughout their healthcare journey.
Hiccups in acquiring prior authorizations can cause major setbacks in patient care. You’re doing everything possible to obtain the necessary care for your patients, but at times, you encounter resistance from the insurance company, which can be frustrating.
But when you know you are right, stand up for your cause. Insist insurers in adhering to their established timelines for processing PA requests. Be diligent in following up to expedite approvals and avoid delays in care.
If a PA request gets denied, use the insurer’s appeals process effectively. Ensure you present a solid appeal with robust documentation to support your case.
In addition, keep detailed records of all your communications. Keep tabs on everything — note down dates, responses, and any delays you encounter. This helps track progress and makes sure nothing slips through the cracks.
Direct communication can be a game-changer in clearing up prior authorization issues. Engage in a peer-to-peer review by speaking directly with the insurer’s medical director or another physician. Use this opportunity to discuss and resolve PA requests by clearly explaining the medical necessity of the treatment or medication. Address any concerns or questions they might have, and back up your case with evidence-based reasons for why the prior authorization request should be approved. Highlight the benefits of the proposed treatment and discuss the potential consequences of delayed or denied treatment, such as worsening symptoms or the need for more invasive interventions.
Growing concerns over prior authorization have prompted state and federal lawmakers to push for policy changes. In 2023, nine states and the District of Columbia passed legislation to streamline the PA process, reducing delays and simplifying approval procedures to ensure faster patient care access.
In addition, the Centers for Medicare & Medicaid Services (CMS) released a final rule that brings significant changes to PA for certain government-regulated plans. It aims to cut patient care delays and improve access to treatments.
Furthermore, over 90 bills have been introduced across 30 state legislatures this year to further these reforms. Some propose "gold carding" programs, expediting PA for clinicians who consistently meet clinical criteria. These efforts signal a shift toward a more patient-centric healthcare system, prioritizing timely care and reducing administrative burdens.
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