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Prior Authorization Management: Saving you time and money

One of the most infuriating challenges for physicians is obtaining prior authorizations for prescriptions and testing. In the eyes of physicians, prior authorizations are nothing more than insurance companies inserting themselves into the care decision-making process, creating problems for both doctors and patients.

Most doctors view prior authorizations as an attack on their autonomy, their years of training, and their ability to care for their patients. Plus, there’s the time wasted and revenue lost due to haggling with payers over approval for drugs and tests. In a recent survey, physicians told Medical Economics that prior authorizations were one of the major problems that were “ruining medicine.”

Prior Authorization Cost Physicians Time and Money

Most physicians and other providers agree that staff time spent on getting prior authorizations form insurance companies takes too much time out of a busy workday that could be spent on other necessary tasks. Unfortunately, a smaller practice’s billing and back office staff may already be stretched to the breaking point, so initiating and following up on “pre-certs” can sometimes be overlooked altogether – at least until a bill comes back as denied for reimbursement.

What steps are some insurers taking to reduce wait times?

Some companies, such as Cigna, are trying to close the time gaps with improved technology that would pull information directly from the EHR. Jeffrey Hankoff¸ MD, Cigna’s medical officer for clinical performances and quality, states that using this technology reduces the need for the provider’s billing and other staff to have to select and submit the correct information needed to approve the pre-cert. While there are still some issues to be worked out, such as HIPAA clearances and information security, it could greatly speed up the process by resulting in fewer initial denials.

Some insurers may be willing to work out deals with practices, such as “gold card” or pre-approved deals on certain types of conditions or treatments requiring pre-authorization. These deals apply to practices that have demonstrated keeping costs low while performance high. Some, like Cigna, have noticed that giving a “free pass” to some practices may cause care quality to slip, so they want to see providers take on some risk as well.

What is the Patients Role in the Pre-authorization Process?

Providers need to educate patients that having insurance doesn’t mean that they will automatically receive an array of tests and treatments on demand. Evidence-based guidelines dictate that unless a given test or treatment is medically necessary, it won’t be covered, whether or not the patient is insured. An example is a patient demanding an MRI for back pain when more conservative, less expensive treatments would serve as well.

Have a dedicated staff integrated into practice workflow

Physicians and other care delivery providers are particularly frustrated with the administrative burdens of prior authorizations. Providers overwhelmingly agree that prior approvals for services and prescriptions are a regulatory burden, delay patient access to care, and create unnecessary work.

Shifting the responsibility of prior authorizations to a dedicated staff could help to reduce the burden on care delivery providers and increase productivity.

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