Prior authorizations can place extreme burdens on physicians. Physician surveys show that the necessity for prior authorizations absorbs inordinate amounts of staff and physician time and can delay the delivery of care to patients. Seeking and implementing best practices for prior authorization tasks is critical if practices are to streamline operations and ensure the delivery of quality care. We are going to examine these issues in a five-part series that will explore best practices for pharmacy prior authorizations, standardization of processes, prior authorization toolkits and electronic prior authorization standards. Today we look at prior authorization best standards.
Prior Authorizations Are a Pain Point For Physicians
A 2016 survey of 1,000 physicians shows how desperately prior authorization best practices are needed to reduce administrative burdens. Of the physicians surveyed:
- 75 percent believe that prior authorization places “high or extremely high” burdens on them and their staff.
- 41 percent spend up to 20 hours each week on prior authorization tasks
- 90 percent report that is causing delays in the delivery of necessary care
- Nearly 60 percent waited at least one day for authorization from a health plan
In 2017, an MGMA Stat poll of 1,000 medical practice leaders found that 86 percent said their prior authorization requirements had increased over the past year. They attributed that to the ever-increasing number of procedures and prescription drugs for which health plans require prior authorization.
As a result of these survey findings, the MGMA, the American Medical Association (AMA) and 15 other organizations have joined together to send 21 prior authorization improvements to health plans and benefits managers, urging them to reduce administrative burdens to improve continuity of care. The improvements, built on five tenets, say prior authorizations should:
- Demonstrate clinical validity rather than focus solely on healthcare cost reductions.
- Promote care continuity.
The tenets call on health plans to:
- Uphold healthcare transparency and fairness in utilization management programs.
- Use utilization management programs to increase timely care access and administrative efficiency (robust electronic adoption).
- Implement prior authorization exemptions to reduce administrative burdens.
In the meantime, streamlining prior authorization practices to reduce administrative burdens falls squarely on the shoulders of each physician practice. Best practices can help.
Prior Authorization Best Practices Eliminate Delays in Care in 2018
When prior authorization best practices are implemented, they result in embedded systems that streamline workflow, reduce administrative time and improve care. Some of the leading prior authorization best practices include:
Electronic prior authorization:
Automating prior authorization tasks leads to time-saving standardization of forms and data entry. When a provider requests a prior authorization, the system can support that request, accelerate response times and improve patient care. When it comes to prescriptions, electronic prior authorization can get patients urgently needed medications quickly by closing approval gaps. The AMA has developed electronic transaction toolkits specifically to help reduce the prior authorization administrative burdens.
Standardize the collection of data:
Establishing consistent documentation requirements within the practice will ensure that the information needed for prior authorization will be in the patient’s medical record. It avoids delays in the delivery of care and reduces the time spent on collecting patient information for prior authorization.
Follow the money:
Prior authorization is still an antiquated process, despite automation and standardization. Dedicating one staff person to follow up on every prior authorization can save the practice a lot of money and prevent it from falling through the cracks. The more one staff person doggedly pursues every step in every authorization, the more money your practice will receive.
Trained staff for expert prior authorization:
When staff is trained to process prior authorizations with the right procedures and codes, approvals are faster. Sometimes contracting with an expert firm is better for the practice. Whether it is a contractor or internal staff person, handling best practices for prior authorizations demand the following skills:
- Well versed in the rules and nuances of medical necessity, CPT-ICD correlations, and patient clinical trials.
- Long-standing expertise with Medicare, Medicaid, dual Medicare-Medicaid, and other commercial payors in over 30 states.
- Experience handling prior authorization for inpatient and outpatient surgeries, hospital admissions and diagnostic imaging.
Spending 20 hours a week on prior authorization tasks benefits no one. Physicians burn out on administrative burdens, patient time is decreased, and delays in approvals prevent the delivery of effective care to patients. It’s time to rope in prior authorization and control it through automation and highly skilled personnel. The results will be increased physician/patient satisfaction and increased revenue for the practice.