Streamlining the Insurance Prior Authorization Debacle (2024)

Will streamlining ever be possible as long as we encounter more resistance in our daily care of patients?

Every day, I learn continuously from each patient I am blessed to care for and from the continued interaction with my fellow physicians. I hope this will continue throughout my career in internal medicine.

A common admonition we are hearing is the necessity to “streamline care” to become more efficient. At the same time, we are bombarded with government interference, EHR modernizations, the ups and downs of contracting with insurance companies, continued issues with billing and collection methodology, and last but not least, dealing with prior authorization. The maddening duties of prior authorization disconnect us from our daily clinical work flow and impede our delivery of care. This process involves obtaining prior authorization from insurance companies for pharmaceuticals, durable medical equipment and medical services. It is a burden that drains practices. It is time-consuming in its antiquated methods of using the fax or the telephone, which interrupts practice work flow and pulls the physician and staff away from their daily patient care.

Here is an example. My nurse was denied a prior authorization request, and a peer-to-peer contact was requested of me with the insurance company. My return call for the peer-to-peer that evening was unsuccessful as they had left after 4:30 p.m. I called the next day—and after being on hold for several minutes—I gave the same information that was delivered to the insurance company the day before. I was immediately given the authorization. The decision seemed to be predetermined without me giving any more information.

I asked the reviewing physician his specialty, and he said that he understood what I as a physician was going through as he had practiced medicine for 15 years. I explained to him that during a prior authorization, much of a physician’s time is wasted. My day is much different than his day as are my concerns as an advocate for the patient—the one affected by the insurer’s determination. I acknowledged that him being in the insurance position is likely the result of him being tired of doing what I have to do in order to practice in this age of medicine.

SLMMS Survey Shows Delays, Restrictions

In December 2016, SLMMS released results of a survey of physicians confirming that St. Louis-area patients are experiencing delays and restrictions in receiving needed care due to insurance company practices in prior authorization.

We undertook this survey to illustrate the problem to the community. Local insurance carriers were rated on a scale of 1–5. “The overall composite score of 3.19 translates to the letter grade of C,’” said Samer Cabbabe, MD, 2016 SLMMS president. “We are very concerned that these delays and restrictions impact our patients’ ability to access needed care in a timely manner.”¹

Findings in the survey revealed that 92% of physicians surveyed agreed or strongly agreed that their ability to practice medicine appropriately is influenced by this process of prior authorization. In addition, 93% somewhat agreed or strongly agreed that they had to alter a patient’s treatment plan because of the restrictions from an insurance provider. “Physicians and their staff spend a significant amount of time trying to pre-certify exams and procedures for their patients,” Dr. Cabbabe added. “They worry this can endanger patients who have illnesses requiring urgent diagnosis and treatment. Patients get frustrated waiting for approvals for these procedures and tests.”¹

Summarizing physician comments provided in the survey, Dr. Cabbabe said, “Physicians are telling us that the pre-certification process makes it more difficult to practice medicine. Patient conditions can worsen while waiting for insurance approvals, which can sometimes take as long as two weeks. … Through this survey, physicians told us they spend more time fighting insurance companies than they spend fighting disease, and that shouldn’t be the case.”

He also noted that physicians object to the level to which insurers insert themselves into a patient’s care. “One respondent asked, why do we allow people from the insurance company who have never seen or examined the patient to determine the care they should receive?”¹

AMA Survey Quantifies Impact on Physicians

A month later, the American Medical Association released the results of its survey on prior authorization. It echoed similar findings of physician frustration and how this process impairs our care to patients and creates potentially harmful delays in care. The enormous time wasted in prior authorization processing and cost to our practices and patients is illustrated in their findings. The bottom line is it affects patient care.

The AMA survey pointed out that during the course of the average workweek, a physician completes an average of 37 prior authorization requests. Physicians and their staff spend an average of 16.4 hours per week completing prior authorization requirements for patient medicines, procedures and medical services that they may need. Some 90% of the surveyed physicians in this AMA study reported that the prior authorization process delays patient access to necessary care. And some of these delays are often lengthy, with 26% of physicians stating that in the prior week, they waited three business days or more on average to receive prior authorization decisions from health plans. The study found that on an annual basis, 853 hours were consumed by tasks related to prior authorization.²

What this means is that one-third of physicians are required to employ staff members who work exclusively on prior authorization duties. These growing diversions from patient care serve as one of physicians’ biggest source of professional dissatisfaction.²

The AMA believes that prior authorization is overused and that existing processes are too difficult. Due to its widespread usage and the significant administrative and clinical concerns it can present, the AMA believes that prior authorization is a challenge that needs to be addressed through a multifaceted approach to reduce burdens on physicians and patients.

In conjunction with the survey, the AMA and a coalition of 16 other organizations representing physicians, medical groups, hospitals, pharmacists and patients issued a comprehensive set of 21 principles designed to dramatically reshape the prior-authorization process. Among other things, the coalition calls for an end to repeated prior authorization requirements for patients already stabilized on a medication for a chronic condition. The coalition also seeks industry-wide standardization of the prior authorization process through electronic transactions that are incorporated into electronic health record systems. The 21 principles encompass clinical validity, continuity of care, transparency and fairness, timely access and administrative efficiency, and alternatives and exemptions.³

In addition to the AMA, the coalition includes the: American Academy of Child and Adolescent Psychiatry, American Academy of Dermatology, American Academy of Family Physicians, American College of Cardiology, American College of Rheumatology, American Hospital Association, American Pharmacists Association, American Society of Clinical Oncology, Arthritis Foundation, Colorado Medical Society, Medical Group Management Association, Medical Society of the State of New York, Minnesota Medical Association, North Carolina Medical Society, Ohio State Medical Association and Washington State Medical Association.³

In 2016, the AMA House of Delegates adopted an in-depth policy on standardization and simplification of prior authorization. Several states have already passed legislation to protect patients from overly burdensome utilization-management requirements, with Delaware and Ohio among the most recent.⁴

Solutions to This Problem

A lot has been said about our problem and how it costs us time, money and good patient care. Now let us examine how the current state of prior authorization fails and a suggested way in which existing obstacles can be overcome. Our current system lacks the foundation of a widely adopted electronic data exchange, resulting in repeated manual methods and no centralized method of processing and responsibility for obtaining the preauthorization.

There are those that feel health care providers can gain tremendously from automated prior authorization screening and verification. This technology can focus on becoming more centralized, and by defining individual roles and working in consistent approaches to prior authorization. Correcting these disjointed processes, and establishing a better process to include real-time scheduling and EHR integration, will enable instant prior authorization decision making.

The present manual processing is no match for the level of complexity, limited commonality and frequency of changes and updates found among both payers and the different plans. It has been shown that among 23 major health plans, only 8% had a commonality in an analysis of 1,300 procedure-specific authorization policies. Many have their own independent prior authorization policies in their many sub-plans within health plans.⁵

Additionally, authorization details generated by a technology-enabled system would give providers a clear understanding of whether an upcoming treatment will be covered by the patient’s insurance, thereby aligning physician and hospital pre-authorization objectives.⁵

Prior authorization is costly—in the range of $35 to $100 per occurrence, according to industry estimates. The cost of processing a claim has dropped to just $0.66 when providers have implemented electronic processing. Imagine what could happen with prior authorization costs when electronic processing ramps up from its current level of only 7% provider adoption?⁵ This would occur by eliminating duplicative reviews, administrative savings, and fewer denials resulting in significant savings.

Automated prior authorization screening is already connecting providers to hundreds of payers, with hundreds more electronically linked payers expected to activate in coming months. Every day, repetitive and costly manual tasks are being replaced by codified and callable payer-specific policies, giving providers more control and making the pre-authorization process consistent and replicable.⁵

The effective use of screening and verification rules can slash the time required for research, while arming providers with definitive answers about whether a given service needs a prior authorization. From all indications, it’s time to get on board with this vital market trend as providers and payers converge on an admission-centric approach with a keen focus on ROI and improved patient outcomes.

There is a real opportunity to improve and significantly reduce the administrative burdens for both the physician and payers along with the patient experience by reforming utilization management and prior authorization programs. Physicians welcome the opportunity in working collaboratively with health plans to create a partnership which will build the foundation for a more efficient prior authorization process. Both the SLMMS and AMA surveys support the urgent necessity for these changes to be made to allow physicians to practice in both a time- and cost-efficient manner as we face these times of health care change and demands.

Biography

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