4. Third-party payer interference in patient care
David Belk, MD, who runs a solo internal medicine practice in the San Francisco Bay area, understands the frustration many doctors feel when insurance companies telling them how to practice medicine and require prior authorizations.
When a patient shows symptoms of diverticulitis, for example, he wants to order a CT scan, but it requires a prior authorization. “I don’t get paid extra for the scan, so why does a nurse from an insurance company have to sign off on that? How is that about saving money?” he told Medical Economics earlier this year.
Physicians are increasingly baffled by payers’ use of prior authorizations for what they say are often routine, low-cost treatments or for drugs that have already proven effective for years at treating a patient.
FURTHER READING: Payers becoming extreme headache for physicians
Interference from insurance companies costs practices time and money. Here are five ways to be more efficient when dealing with prior auths.
1. Document the details
Brief practice staff members on the importance of thorough documenting of symptoms and prior treatment measures. Payers need to see everything that’s been done for a patient and details of all the symptoms. The more they know, the less likely they are to challenge a doctor’s decision—or waste time by asking for details they should already have.
2. Know prior auth medications
Create a list of medications that commonly trigger prior authorizations, either in the EHR or on paper. Note which medications are on a payer’s formulary and keep that list updated. If physicians check the list before prescribing, many prior auths can be avoided.
3. Loop in the staff
Physicians are often focused solely on delivering the best care and not what payers are pushing back against. Encourage nurses and practice staff to keep all providers informed when prior authorization issues arise and to point out any tests or medications that continually create difficulties with payers.
4. Work with payers
Many prior authorizations may be unavoidable, but practices can still save time by finding out how payers prefer prior authorization communication and what details they are looking for.
Track the types of care for which payments are being denied. Are there recurring administrative errors that can be corrected? When a prior auth goes well, have the staff note how the information was delivered and to whom and use that same approach for future requests. Is one staffer getting approval for a particular treatment that gets denied when others request it? Examine the differences between approvals and denials for the same treatment.
5. Share the criteria
Once the payer criteria for prior authorizations is known, keep it handy so physicians in the practice know what kind of information to include in the request to better the chances of success. If possible, assign a staffer to particular payers so they are familiar with the requests and the rules for prior authorizations. These connections can lead to smoother approvals in the future.
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