Prior authorization (PA) is time-consuming and fraught with administrative and financial burdens for physicians and their staff, typically requiring extensive communication and follow-up for disruption due to prior authorization. A recent American Medical Association survey revealed that physicians and their staff spend an average of 13 hours each week completing PA requests. On an annual basis, that is nearly 853 hours dedicated to prior-authorization tasks. The time burden is so great that about one-third of physicians have staff members who work exclusively on prior-authorization duties.
Even more frustrating is the fact that 93% of physicians say that PA delays patients’ access to necessary medical care, and 82% of physicians report that PA processes also result in abandonment of treatment. Other studies have linked prior authorization to treatment delays, emotional distress, and worsening symptoms. Also, a survey conducted by the AMA reported that 88% of providers classify the burden of prior authorizations as high or extremely high. Besides the significant investment of time and energy, Prior Auth is also extremely expensive for a practice to undertake.
Inevitably, groups such as the American Medical Association have raised concerns about the cost burdens of PA. Estimates of the cost burden to physician practices vary considerably, in 2010 it was estimated to be from $80,000 annually per physician to between $2,200 and $3,400 annually per physician. It should come as no surprise that The Centers for Medicare and Medicaid Services (CMS) proposed a new rule to advance interoperability and improve the prior authorization process. The intent behind CMS’s move is to foster transparency, reduce physician burden, and speed-
However, the provisions for the CMS rule will not go into effect until 2026. Meanwhile, it is up to practices and their partners to manage prior authorization the best that they can. This begins with understanding what disruption due to prior authorization is, along with why it is necessary.
1. What is prior authorization in healthcare?
Prior authorization is a utilization management process primarily used by healthcare payers. This process requires that certain treatments or prescriptions which are prescribed by clinicians to be evaluated for medical necessity and cost-of-care ramifications before they are approved and reimbursed.
2. Why is prior authorization a necessity?
This process was formulated to ensure that patients receive safe and effective treatments. Payers = can see how a covered patient utilizes their coverage and what treatments they may have previously received, thus helping prevent duplicate and unnecessary treatments for disruption due to prior authorization.
3. Why is the prior authorization process complicated?
- There are a number of steps in the process, and each introduces the potential for delays and errors.
- It involves participation by both payers and providers who often have different motivations and priorities for disruption due to prior authorization.
- The want for consistent standards, particularly when it comes to payer guidelines.
- Highly volatile payer rules and policies.
- A need for manual reviews of prior authorization requests and medical charts by clinicians.
4. How to expedite your disruption due to prior authorization process.
- Create a list of required prior authorization for each payor to streamline your process and reduce call times.
- Track the reason for denial and the payor anytime you receive a denied authorization, to avoid repeating the same errors in the future.
- Build an up-to-date master list of the medications and procedures that require for disruption due to prior authorization, and break it down by insurer.
- Automate your prior authorization process.
- Train every clinician in your practice to prepare a well-articulated appeal. Most of the time, the specialist can make a successful appeal, but some cases may require the health care provider.
- Only submit complete requests that are backed up by well-documented data.
- Having a physician get on the phone for a peer-to-peer discussion can save time as it is sometimes only the doctor who can argue necessity for disruption due to prior authorization and provide literature supporting their treatment decisions.
5. How to outsource your prior authorization
Outsourcing your prior authorization processes can help to reduce administrative burden and enable you to improve your bottom line. At EMPClaims we specialize in Revenue Cycle Management services including prior authorizations and help to simplify complex medical billing operations. Want to learn more about disruption due to prior authorization?
Visit our website for more ways to master the prior authorization process.