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The payer time drain: dealing with prior authorizations


Despite recent moves to streamline the prior authorization process, physicians still struggle mightily as they jump through payers’ hoops.

Despite recent moves to streamline the prior authorization process, physicians still struggle mightily as they jump through payers’ hoops.

Eight in 10 respondents to the Medical Economics Payer Scorecard of nearly 1,100 physicians reported that prior authorizations represent a significant challenge. A separate American Medical Association survey in December found practices are handling an average of nearly 37 requests per week, per physician.

It’s not just the number of authorizations, but the implications for patient care that are concerning, physicians say.

“Sometimes it’s just a real hassle, and sometimes it’s also a financial hit,” says Kenneth Kubitschek, MD, FACP, an internist with an Asheville, North Carolina-based practice and a member of the Medical Economics editorial advisory board. 

Kubitschek says he has received pre-approvals for stress echocardiograms that were later denied when a patient couldn’t complete the stress portion. But he continues with the test because, he says, it’s the right thing to do for the patient rather than rescheduling the procedure once he’s obtained a new approval.

Delegating prior authorization calls to staff members doesn’t always work either, because some payers insist on speaking with the ordering physician, he says. And at the beginning of each year, payers typically make changes to their contracts with pharmaceutical manufacturers, so there are new medications that sail through the process, while some existing ones no longer do.

Like Kubitschek, other physicians are battling obstacles in trying to do what’s best for their patients, while finding solutions to combat a cumbersome prior authorization process.


Pick the right players

In the Medical Economics survey, practices reported spending an average of 19 hours of physician and staff time per week on prior auths.

Dedicating a staff person to obtainingauthorizations, as well as developing a care coordination protocol, has helped reduce time spent on the process, says Jennifer Aloff, MD, a primary care physician practicing in Midland, Michigan. 

Mary Ann Bauman, MD, an Edmond, Oklahoma-based internist and member of the Medical Economics editorial advisory board, says fax and email authorizations, while not fully electronically integrated with electronic health records, have also reduced staff time spent waiting on the phone for approvals.

Drug dilemmas

Pharmacy orders tend to generate the worst  teeth-gnashing, says Marc O’Connor, MBA, chief operating officer for Curant Health, a Smyrna, Georgia-based medication management firm that assists providers with prior auths. Payers increasingly deny higher-cost drugs unless patients have first tried less-costly ones, a process known as step therapy.


In addition, prescription drugs are such a routine part of primary care medicine that they are involved in a high percentage of patient visits, so the sheer volume of authorizations is daunting. “The growth of specialty medications has thrown a wrench in everything,” O’Connor says. 

The prior auth process isn’t limited to pricey brand-name drugs, however, says John Meigs Jr., MD, a primary care physician in Centreville, Alabama. “Patients are different and their responses to medications are different so not every drug works for every patient with the same problem,” says Meigs.

“We have newer meds that work better with fewer side effects but they are expensive and some companies don’t want to pay for them,” he adds. 

Meigs says some payers have become better at telling practices which alternatives they cover, but there is still no universal set of guidelines among payers, and requirements such as step therapy remain common.

Lynne Lillie, MD, recalls experiencing some shock last year when a colleague mentioned being asked by a national retail pharmacy chain to fax a year’s worth of a patient’s medical records regarding a prescription for routine diabetic supplies. Then, a few months later, Lillie herself got a similar request. 

Payers are also moving much of the process online, Lillie says, which can help reduce time spent on hold, but requests often call for more work than what can be accomplished by checking a few electronic boxes.

“We’re getting some relief, but not nearly enough,” says Lillie, a primary care physician in Rochester, Minnesota. “It’s almost impossible to stay ahead of the game.” 


To charge or not

Some practices charge patients for time spent obtaining prior auths, while others say the potential backlash from both payers and patients doesn’t justify the practice. Practices considering this step need to review their payer contracts carefully, as some prohibit such charges.

Keith Dinklage, MD, a primary care physician in New Castle, Indiana, doesn’t accept insurance, but will help patients submit insurance claim forms and occasionally charges $5 for prior authorization work, depending on the situation. 

“Patients are understanding of the time involved,” he says. He thinks if a payer is requiring the prior auth, it should at least share in the cost on behalf of the patient, an idea echoed by Meigs.


When insurers change the formularies on what drugs require prior authorization, Dinklage says, they should be held responsible for at least some of the administrative time needed to adjust.

Keeping up with formulary changes isn’t always straightforward, adds Jeffrey M. Kagan, MD, an internist in Newington, Connecticut and a Medical Economics editorial advisory board member. 

Often, he says, payers will simply start denying requests instead of pre-publishing a list of which preferred drugs are on their formularies. And they will frequently issue an authorization that expires in 12 months, and so will resume denying coverage after that time period, even if the drug remains on the preferred list and the prescription is still active.


Advocate for yourself

Though payers’ prior authorization rules generally don’t allow for flexibility, some doctors are attempting to use their quality scores to make a case for reducing prior auths.

As part of a patient-centered medical home, Aloff’s practice has been highlighting its low rate of emergency department visits and radiological equipment use, for example, when it negotiates with payers. 

A North Carolina insurance company waived prior authorizations for Kubitschek’s practice a few years ago after the practice had gone a lengthy period with no denials, he says. But the reprieve only was good for about a year and then it was back to square one, despite the practice winning awards for cost-effective care.

“It makes sense that if you’ve proven yourself over time, you shouldn’t have to go through the silliness,” he says. “It just drives another wedge in the doctor-patient relationship.”

Be aware, however, that there are times when speaking up for a specific patient may put a practice at risk for losing contracts, warns Kagan, who has written letters to payers requesting they cover pricier drugs for certain patients.

 “I understand that when I write these letters I’m at risk of de-selection” as a provider under a payer’s contract, he says.  

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© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health