5 strategies to lessen the burden of prior authorizations on today’s medical practices
Prior authorizations made headlines most recently when a Department of Health and Human Services Office of Inspector General (OIG) report revealed that Medicare Advantage plans delayed and denied patients’ access to medically necessary treatment. This isn’t necessarily ‘new news’ to medical practices nationwide, many of which continue to struggle with helping patients get the medically necessary care and services they need. Eighty-eight percent of respondents to a recent Medical Group Management Association (MGMA) survey said prior authorizations were ‘very’ or ‘extremely’ burdensome.
What makes prior authorizations so challenging?
It takes time and resources to submit prior authorization forms and other documentation manually via fax or through the health plan’s proprietary web portal. Staff must also stay abreast of ever-changing medical necessity requirements and appeals processes to meet each payer’s unique requirements.
In theory, prior authorizations are meant to control costs. However, in reality, the prior authorization process oftentimes delays care unnecessarily and sometimes at the expense of patient outcomes. Thirty-four percent of physicians say prior authorization has led to a serious adverse event for a patient in their care, according to a recent survey from the American Medical Association (AMA).
The good news is that new legislation may address the burden of prior authorizations. In addition, the AMA submitted comments in response to the Office of the National Coordinator for Health Information Technology’s (ONC) request for information on electronic prior authorization. Specifically, it urged ONC to consider strategies to reduce prior authorization volume, denials, and delays, improve prior authorization transparency, protect the continuity of patient care, and more. In its comments, AMA said, “ONC must consider how its Certification Program will leverage certified health IT to achieve comprehensive and much-needed [prior authorization] reform.”
Prior authorization steps: How to improve efficiency
In the meantime, is there anything else medical practices can do to streamline prior authorizations? Yes. Consider the following strategies:
Know what does—and doesn’t—require a prior authorization. Create a master list for each insurer that includes all prescription drug prior authorizations as well as prior authorizations required for medical services and procedures. Instruct physicians and other clinical staff to refer to these master lists before providing services or sending prescriptions to the pharmacy.
Appoint someone in the medical practice to stay on top of changes. This includes monitoring health plan provider newsletters, bulletins, and websites for any updates. Note that a prior authorization specialist doesn’t need to be a separate full-or part-time position. With proper training, a coder, biller, medical assistant, or front-desk staff person may be able to assume these responsibilities.
Focus on documentation. This includes saving and filing payer newsletters, printing out payer web pages, noting the details of any phone calls regarding prior authorization, and more. It also includes consistently documenting clinical data required for the prior authorization, such as ‘step therapy’ for prescription drug prior authorizations or any prior care that’s been provided to the patient. When medical practices know what payers expect in terms of documentation requirements—and they provide this documentation the first time around—this avoids delays in patient therapy and prevents potential follow-ups with patients for additional information.
Consider an automated prior authorization process. Some electronic health record vendors provide electronic prior authorization solutions or can integrate with vendors that do. Using standard electronic transactions can increase uniformity across health plans and streamline practice workflows. If a health plan doesn’t accept automated prior authorizations, medical practices will need to use one of the following alternative methods instead: Payer portal, multi-payer portal, fax, telephone, or secure email. Each method has its pros and cons, and it’s important for medical practices to understand each option and choose the one that’s most efficient for each circumstance. Doing so minimizes workflow disruptions and reduces the time staff spend on prior authorization efforts.
Regularly follow up with payers to ensure timely prior authorization approval. For example, consider using a ‘tickler’ (reminder) system to trigger follow-up communications to ensure prior authorization requests don’t fall through the cracks. Electronic prior authorization helps provide transparency into submitted and pending requests. It can also help practices automate the prior authorization appeal process for prescriptions.
For more information about how medical practices can streamline prior authorizations and comply with prior authorization steps, view these prior authorization practice resources from the AMA.
Conclusion
Prior authorizations continue to challenge medical practices, however, there are steps practices can take to reduce the burden. In addition, regulatory changes are already underway to improve the prior authorization process. To learn more about how technology can help, visit https://www.edgemed.com.
