Of all the bureaucratic practices in American healthcare — and there are many — there is one that seems to annoy health care providers more than most. You know what I’m talking about: Prior authorizations.
Prior authorization is a health insurance cost-control practice that requires providers to obtain approval before a prescribed treatment, test or medical service qualifies for payment. It is a tool that can help align patients’ care with their health plan benefits. But over the years, prior authorization — aka preauthorization, prior approval, or precertification — has become an administrative quagmire for providers, creating unnecessary delays in patient care and wasting valuable time and resources.
Nearly eight in 10 physicians (79%) say that the administrative process often or always delays access to necessary care and 30% of them reported the prior authorization has led to a serious adverse event for a patient in their care, according to a 2020 survey by the American Medical Association. The burden has grown as prescription drug coverage became more widespread and spending on pharmaceuticals has increased.
The survey findings show that medical practices on average complete 40 prior authorization requests per week, up from 29.1 from an AMA physician survey in 2018. Physicians and their staff spend an average of 16 hours per week, or two business days, on the workload.
These requests are so time consuming and cumbersome because the processes remain all too often manual and vary widely among health plans and insurers. There are a plethora of payer-specific prior authorization forms, and the forms often lack clarity and do not contain all of the information required by payers to make a determination. This necessitates more communications with payers, more patient records to unearth, and faxes — yes, faxes — to be sent.
You probably have your own administrative horror stories, but I’ll share just one that I recently came across in a published report. A representative of the Cleveland Clinic once testified before the Ohio Legislature that repeat faxes had to be sent 430 times each month because the first one wasn’t acted on. And at least 2,000 times a month, five-plus calls had to be made to insurers regarding the status of a prior authorization request. SMH.
While this kind of effort is extremely burdensome on providers, insurers also spend significant time and resources handling prior authorization requests. The AMA and other healthcare organizations have been advocating for years to reform the process. They seek policy changes, such as more selective application of prior authorizations, more standardization of requirements, and more protections for continuity of care.
The issues are complicated, and strides have been made to reach consensus. In the meantime, providers and payers can take steps to improve communication and collaboration. The current manual process is a prime candidate for automation.
Electronic prior authorization technology provides an efficient alternative to current fax and mail. Requests are integrated into the providers’ electronic health record system. Portals are created to share documents, create timelines and prompts. This allows case managers to track every step of the process and pinpoint where delays are happening. It holds all stakeholders, including providers, health plans and their partners, accountable and rewards those who are working in a timely manner.
Prior authorization comes between you and your patients’ care. Isn’t it time to start taking steps to fix the process?
Aidin has added new features to its platform to help streamline the prior authorization process. Contact us to learn more.