No matter how much physicians loathe the process of having to engage in a back and forth conversation with the healthcare insurance provider before going through with the medication or procedure, prior authorization as of now is mandatory.
What is prior authorization?
While deemed as an insult to the qualification and integrity of the physicians, prior authorization is significant in the healthcare industry. Only when the medical practitioners have the approval from the concerned organization such as healthcare insurers regarding the necessity of the process or medication, can the patient be delivered the same.
What is the goal behind the implementation?
- It is requested to ensure that the medical processes that people covered under medical insurance are going through is medically necessary.
- The patient is provided with the most economical medication or undergoes a procedure with a reasonable bill, without compromising on the efficacy of the treatment and care. This way, prior authorization helps in keeping a check on the healthcare costs.
- The patient is provided with the up to date follow up and recommendation for the medications or the procedure that they have gone through for their medical condition.
- This helps in preventing dispensing similar treatment by multiple specialists. Take, for example, if various specialists are involved in your case, and they require X-ray, which has been done a few days back. PA would not sanction a duplicate treatment unless the same procedure is necessary to perform the second time.
- Patients can no longer be overprescribed as the prior authorizations limit the healthcare provider’s ability to prescribe only the necessary medications.
What are the challenges to adopting prior authorization?
- While keeping a tab on healthcare cost and only delivering what’s necessary can help patients save significantly on their medical bills, prior authorizations have been the focal point of various controversies.
- Per most of the physicians in the United States, prior authorization is nothing but a way of the healthcare insurer to interfere in the decision-making process of the care delivery system. Per research by The Medical Economics 2018, physicians invest 20 hours per week, on an average in dealing with the prior authorization issues.
- Prior authorization is especially a roadblock in dispensing quality care and treatment to the patient’s requiring immediate and extensive treatment. The continuous back and forth will delay the progress, which can be detrimental in some cases. A survey from the American Medical Association stated that the patient’s treatment is delayed by 3 to 4 days waiting for the prior authorization approval.
- Considering the amount of time that is spent in ensuring proper communication between the providers and the healthcare insurers, medical practitioners, and healthcare organizations consider it an administrative burden. Regarded as the most burdensome requirement in Medicare by the Health Business Management Association, physicians across the nation are calling for reforms in the cumbersome way the process is carried out.
- A recent survey done by The American Medical Association states that 28% of the physicians think that the prior authorization process delays the entire functioning of the system and has an adverse impact on the productivity and efficiency of the medical staff.
How is CMS working to ease the process and minimize the administrative burden?
CMS and America’s Health Insurance Plan are working on devising an integration system that lessens the burden. Understand the need of the hour, and AHA has requested CMS to build a method that streamlines how prior authorization will be requested and received.
Development in electronic tools might help ease the request and response process for both the payers as well as the providers.
How can you minimize the burden of the prior authorization in your facility?
- While no healthcare facility can escape prior authorization, all that can be done is providers come up with strategies that can lessen the PA stress. We have listed some tips that can be of help:
- Delay in dispensing care is a hurdle which physicians believe has been imposed by the PA system, but it can be minimized to an extent by the practitioner’s itself. Create a team solely dedicated to managing the prior authorization. They will make sure that before you can start with the procedures, all PA requirements have been met. Staying updated with the payer’s rules and regulations and periodically documenting them can speed up patient care.
- Having a dedicated team of trained and certified medical technicians can help minimize the time spent in researching if submitting the request for approval. Integrating the staff with the latest tools and technology, such as workflow management software can help minimize the administrative burden on the providers and the staff.
- Research how your payers prefer the prior authorization communication and strategize accordingly- be it through fax, phone, or electronic mediums. This will help in speeding up access to patient care.
- Implementing and utilizing a fully automated prior authorization strategy can help not only significantly reduce the time and money that is otherwise drained in these processes which include higher denial plausibility, but also minimize the probability of errors. Electronic prior authorization is one such way of realizing this goal. While still awaiting approval, the prior electronic authorization will only be a stepping stone to what more can be done in reducing the administrative burden. It will give way to artificial intelligence, application program interface, and more.
- Simplifying prior authorization is not just the responsibility of the providers but the patients as well. Providers will have to educate patients about the importance of prior authorization. Many a time, physicians encounter a situation wherein the patient is adamant on getting an MRI to check for something when it is not required, and a less extensive treatment can quickly treat the medical condition.
- One rather unconventional method which requires rigorous though the processing is not accepting insurances at all and going direct. If not done with careful consideration, this can haywire the healthcare business’s model. For medical practices that are tired of payer contracts and the involved back and forth, this is an ideal way out.
