Prior authorizations: A payer's perspective

Physicians view prior authorizations as frustrating, time-consuming barriers to obtaining the care their patients need. But for at least one major insurance company, they are a means of ensuring that the treatments patients receive are safe and meet evidence-based guidelines.

When deciding whether to authorize a particular medication or test, “probably the most important rationale is appropriate use,” says Edmund Pezalla, MD, vice president and national medical director for pharmaceutical policy for Aetna, Inc. “We’re trying to make sure this is the right thing for this patient. And if there’s something about the patient that is a safety issue or that suggests there’s a different way to go for treating that patient, to ensure those things are being considered.”

An element of the appropriateness-of-care consideration, adds Pezalla, is “are there alternatives that are perhaps less expensive or less involved that have already been tried? And is this a procedure or pharmaceutical that’s been proved to work for this type of patient, or is this something experimental?” If it’s the latter, “then we’re looking to have the physician help us see that there is sufficient evidence” before proceeding, Pezalla says. 

Whereas until fairly recently most medical care was based on intuition and guesswork, Pezalla adds, today evidence-based guidelines are available from medical societies and the government for a great many more treatments and therapies. The purpose of prior authorizations, he says, is to ensure that the procedure or medication for which coverage is being sought is consistent with guidelines.

“It is the role of physicians to figure out the appropriateness of care, and most of the time we should agree on where the evidence leads us. In instances where we disagree, we have opportunities for physicians to talk to us about those disagreements,” Pezalla maintains. 

The majority of initial denials, he adds, times they are because of missing information needed to ensure compliance with a guideline-most commonly either previous treatments of the disease, the disease’s subtype, or current therapy. “The most common reason for something to be denied then overturned on appeal is the provision of new information from the doctor’s office,” he says.

NEXT: Prior authorization advice for physicians

Pezalla recommends physicians take the following steps when seeking a prior authorization:

• Look on the payer’s website for its prior authorizations criteria

• Give the person submitting the authorization request access to the patient’s chart, so that they have all the required information

• Include a note in the chart information about why the patient needs a particular medication or treatment, or exceptionto a payer’s rule

• Use e-prescribing technology (“Many now have built-in formularies that tell the physician what will require a prior authorization, and they can begin the process before sending it to the pharmacy,” Pezalla says.)

Even with all that, Pezalla acknowledges, misunderstandings and frustrations can ensue. “There is a communication difficulty, in that the physician often has an intuition about the patient along with the objective data, and it can be difficult to transmit all that information in a succinct way. Sometimes you almost need a grand rounds to get it done.”