Despite continuous movement to streamline the prior authorization process, physician practices are still struggling with jumping through hoops to have procedures and medications covered. A prior authorization (PA) is the process insurance carriers have in place to approve or reject prescriptions based on plan formulary. The PA process is important in ensuring appropriate and cost-effective therapy, but poses unintended consequences in practices that can cause delays in treatment for days or even weeks.
Dealing with PA requests consumes a significant number of hours for physicians, nurses and clerical staff, which negatively affects the practice workflow and the provider’s ability to spend time with patients. Findings from multiple studies provide evidence that 54% of physicians reported spending a least one hour a day fulfilling PA requirements, indicating the prior authorization process is time consuming.1 Additionally, the cost estimate to the U.S. healthcare system for investing time in the PA process is $23 billion to $31 billion each year or $82,975 to $85,276 per full-time physician.2
With the changing formulary guidelines in place, the PA process is becoming increasingly unpredictable. The winning approach for providers to improve their process is to create a strategy that requires consistency, including dedicated personnel and oversight. Practice administrators and managers will need to manage the process and help staff to prioritize this key component of the practice’s finances.
Practice staff can take some simple steps to minimize the costs and time it takes to handle PAs needed for a procedure or medication. It is important to remember that these steps are not a guarantee of payment, but rather recommendations to assist practices.
- Check PA requirements before providing services or sending prescriptions to the pharmacy. Taking this step will help prevent delays to filling prescriptions, denials of claims and lost payments that can result from unmet PA requirements.
- Select the PA method that will be most efficient, given the particular situation and available options. A variety of prior authorization methods are available, which include standard electronic transactions, health plan portals, fax, telephone and secure email.
- Establish a protocol in the office to consistently document data required for PA in the medical record. Uniformly following a protocol can help avoid delays in patient therapy, prevent potential follow-ups with patients for additional information and minimize time spent on PA.
- Create appropriate reminders for PA to keep them current at all times. This is a key component to maintain continuity with procedures and treatment options for patients. Not all carriers have the same timeline for approved PAs, and because they vary, it is important to have reminders in place so there is no opportunity for payers to deny the claim.
- If a PA is inappropriately denied, submit an organized, concise and well-articulated appeal with supporting clinical information. You can increase your chances of success in overturning a PA denial by making sure all clinical information is included with the appeal, including any data that may have been missing from the initial request. For prescription appeals, think about adopting electronic prior authorization technology to further streamline the process.
Leveraging technology to develop an efficient and effective process for PAs is another benefit to the practice, including Internet portals and the technology that is available through electronic medical records (EMRs). It is also beneficial to have the forms required for the drugs and procedures that most commonly require a PA easily available, either in hard copy or electronic. That way when a “prior authorization necessary” alert comes in, staff can easily locate the necessary form(s).