Dealing with the hassles of prior authorization

Of all the myriad hassles and annoyances that practices have to deal with, prior authorization ranks right up there at the top. Whether these authorizations are related to medications or referrals to specialty care or testing, the end result is a lot of time spent by physicians and staff not on patient care but on burdensome administrative tasks.

It is patients who suffer the most from the inefficient requirements of prior authorization, through lost time waiting for approval; less effective drugs; delayed diagnosis or treatment; sometimes abandoned medications, testing, or treatments; and higher premiums and copayments.

There are studies that show that prior authorization is a measureable cost to clinicians. Until such time as the medical world can effect reductions in the use of prior authorization, here are some tips that practices might try to mitigate some of the burdens.

Look for trends and tackle accordingly. Is it a particular payer? Do certain drugs or tests require prior authorization? Is it a particular quantity or dose of the medication that triggers the request? Sometimes a practice can negotiate an acceptable protocol (such as for common tests, conditions, or medications) and get advance preapproval.

Standardize whatever you can. If certain medications are a problem, take a look at the formularies. Is there a satisfactory substitute? Sometimes clinicians simply do not know what is on the formularies, so for drugs commonly triggering prior authorization, have practice staff check the formularies for the various plans and create a sheet with a list of acceptable alternatives. Have prewritten letters requesting prior authorization for common drugs and/or diagnoses. Involve the patient if necessary.

Is there an online option? Some payers have Web sites with authorization portals, which can sometimes offer faster response times. Create a list of insurance companies that have this option and the URLs for each.

Is there a way that your electronic health record (EHR) vendor can help by automating some processes? Some EHRs can be set up so that when a drug or test requiring prior authorization is prescribed, a task is automatically generated for appropriate staff and a report is printed that includes all the information reviewers will need. This can also trigger staff to set up a follow-up appointment and thus avoid extra phone calls between the office and the patient. Practices should also make sure the formularies are updated in the EHR system.

If a certain insurance company is a problem, contact the representative and try to negotiate a solution. At least this gets the issue out in the open and the company may offer an alternate process for specific situations, conditions, tests, or drugs. If necessary, appeal to a higher level within the rules of your contract with the payer.

Look inside your practice. Are certain clinicians ordering drugs or tests that require prior authorization more often than others? Sometimes education can help. Develop protocols for ordering brand-name drugs and high-cost testing.

Some practices have found that assigning all prior authorization to 1 individual on staff helps to streamline the processes. That person then becomes familiar with the people, diagnoses, forms, fax numbers, Web sites, and other processes at each payer and can be a resource to prescribing clinicians.

Can it be outsourced? There are outside entities that do certain prior authorization work, particularly regarding medications. These companies know all the tricks, have trained staff, and can complete the process efficiently. Although it is an extra step, it may result in less overall time spent by practice staff.

When appropriate, let patients do the upfront work. Provide them with all the information they need, such as diagnosis codes, and let them call for coverage. Not all patients will want to do this, but sometimes a patient's voice can tip the insurance scales more successfully than a clinician's office.

ACP and other medical societies are working on ways to improve the situation. In an effort to ameliorate the significant burden that prior authorization places on practices, last year ACP presented to the National Committee on Vital and Health Statistics regarding operating rules related to prior authorization of referrals and other health services. The goal was to advocate for payers to use technological methods of obtaining the information they need to approve the services so that some of the legwork can occur behind the scenes and not involve so much human time.

For more information about ACP's Patients Before Paperwork initiative, go online .