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How approval hassles for ordering tests or prescribing drugs can get in the way of caring for patients.
The logistics of prior authorizations were increasingly sapping the time and patience of employees at the practice of Hoan Pho, MD, an internist in San Antonio. Not only that, the doctors in the practice were noticing more “bounce backs,” with insurers requesting additional clinical information. “[This is] time that’s really not reimbursed,” Pho says. “We are really doing it because we love our patients-we want them to get the quality of care.”
Increasingly, prior authorizations have become the bane of a physician’s daily practice management. A 2011 Health Affairs study found that U.S. practices spend nearly 21 hours a week per physician and related staff on the process (one hour weekly involved the physician).
David Gans, MSHA, a study coauthor and senior fellow of industry affairs at the Medical Group Management Association (MGMA) in Englewood, Colorado, says that figure would be higher if the study were repeated today. Gans adds that more recent feedback from practices indicate that prior authorizations are increasing nationwide, both in number and scope. “Unfortunately they’ve become routine,” he says.
To ease the workflow strain, Pho and his colleagues have strived to better brief staff on each patient’s medical history, to help them document in more detail which symptoms and prior treatment measures led to the request. Pho estimates that 80% of such requests now get approved on the first attempt compared to about 60% two years ago.
As Pho learned, practices can take preemptive steps, working with staffers and within the medical documentation itself to reduce the time and stress involved in obtaining prior authorizations.
“What you are trying to do is look at short-term investment of time and efforts to develop the process,” Gans says. “And then there’s a long-term benefit so that the whole organization is more efficient.”
One perennial challenge is the lack of standardization among payers, Gans says. They may differ in the clinical details they request or even the manner in which they prefer the information to be provided, whether that’s via fax or electronically, he says.
But don’t worry about all of the practice’s payers both public and private, Gans recommends. Instead, focus attention on the handful that insure the majority of your practice’s patients and build information summaries of those payers’ requirements that can be kept in a central location.
That way, when a particular insurer needs to authorize a diagnostic test, for example, the details of what that insurer typically require are readily available. “Essentially you’re building custom reports, but you only have to build them once,” he explains.
The most common reason for denying a prior authorization is incomplete information, says Jeffrey Hankoff, MD, a medical officer at Cigna. The insurer might receive a request to cover bariatric surgery, he says, that doesn’t have the necessary clearances, such as a mental health evaluation. Or the patient’s weight is included but not the height so the body mass index can’t be calculated.
“My goal is for us to get to the right answer the first time,” Hankoff says. “I’m not interested in putting up road blocks for providers or making anything difficult.”
Hankoff says he’s “very, very much aware of the annoyance factor” around prior authorizations, but they help to verify that medical care is being used appropriately, particularly in the face of rising costs such as for prescription drugs.
More than 80% of Cigna’s business is through self-funded employers and the payer only administers these plans. In turn, the employers audit Cigna’s performance, Hankoff says. “They want to make certain that if we’re approving care, that it is necessary.”
For their part, as practices review workflow they can track what types of care are being denied, Gans says. Is there a recurring cycle of administrative errors? Conversely, pay attention to successes. For example, why is one staffer getting the go-ahead for a particular treatment that is being denied when others request it?
Ask physicians in your specialty whether they’re struggling to get their requests through the first time, Gans advises. If they aren’t, see if a nurse or a medical assistant in your practice can spend an hour or two shadowing their approach, he says. “What are the tips, tricks and traps, so to speak.”
Sometimes, the problem might not be insufficient detail but too much, Gans says. “The insurer, they want the information they need. They don’t need everything. Sometimes too much information obfuscates-gets in the way of what you’re supposed to have. They can’t find it.”
Nearly two years ago, Roy Benaroch, MD, was taken aback to learn that the documentation and phone time involved with prior authorizations was consuming roughly half of each day for the practice’s two telephone nurses. “I was amazed that it was so ubiquitous,” he says. “It kind of snuck up on us.”
So the nine doctors in the suburban Atlanta primary care practice decided to fight back. They learned which medications are likely to trigger an authorization requirement and have encouraged the nurses to alert the physicians as well, Benaroch says.
The time involved has since plummeted, Benaroch says, estimating that each of the two telephone nurses now spends no more than 10% of each day on prior authorizations, freeing up hours for more patient-centered tasks, rather than “just sitting there doing these forms and waiting on hold.”
Benaroch believes the most effective step in reducing preauthorization time was encouraging nurses and other staffers to keep the doctor better informed. “The docs were prescribing medicines and the staff was taking care of these prior authorization problems and I think most of the time, the docs were just unaware,” he says. “As far as they knew, everything was going smoothly.”
Not only did notifying the doctors provide them the opportunity to consider other treatment options, it also highlighted the staffers’ prior authorization workload, Benaroch says. “Both which drugs were triggering it, but also the sheer quantity [of them].”
Linda Girgis, MD, a primary care physician in New Jersey, says her staffers try not only to have all of the information handy before they get on the phone, but they make their calls at times when the two-physician practice is less busy. Since Girgis and her husband are in practice together and their work hours can be staggered, that creates some opportunities when patients aren’t in the waiting room, says Girgis, author of
“Inside Our Broken Healthcare System.”
Even so, she counts herself among the pessimists. “It seems like prior authorizations are more often resulting in denials than they did in previous years,” Girgis says.
The American Medical Association (AMA) provides prior authorization guidance, including an online toolkit and tip sheet. One of those tips: when communicating with an insurer, whether it’s via fax, electronically or by phone, practices should select the method that best suits not only the practice’s workflow but the insurer’s needs.
Yul Ejnes, MD, a general internist in Cranston, Rhode Island, says he defers to the judgment of his staffers, because they’ve learned through experience the most efficient communication approach with each payer. Also, electronic health records (EHRs) have helped to head off the need for some requests.
Depending upon the insurer, the system might use a symbol to indicate that a medication is on the pharmacy’s formulary, he says. “We can sometimes see which of three equally appropriate options would be preferred versus requiring a prior authorization.” Making sure those EHR formularies are as up to date as possible, by working with information technology and other vendors is key, he says.
Ejnes also keeps insurer criteria for imaging tests handy by linking to websites or downloading documents on the computer in the patient exam room. Otherwise he might neglect to include, for example, that a patient who needs an MRI of the spine not only has back pain radiating down one leg with numbness, but also has tried physical therapy without any improvement.
“What kind of information do you need to have in your request to have it passed on the first try?” Ejnes says. “If you know the rules, it makes it a bit easier to play the game.”
Medical practices also can structure their workflow to assist staffers in building long-standing connections with specific insurers, says the MGMA’s Gans. One approach is to assign a staffer to handle paperwork for one or two insurers, so they become steeped in the processes involved and get to know those working on the insurer’s side of the phone line, he says.
Marilyn Heine, MD, an oncologist in Langhorne, Pennsylvania, says those types of working relationships can be invaluable, such as when time is of the essence to start treatment and authorization is needed. At her practice, which has five doctors and a nurse practitioner, four staffers work either half-time or nearly exclusively on authorization requests. “The skill set that’s required and the relationships that are developed through this process are invaluable to having a productive outcome,” she says.
Heine’s staff also has developed a system to stay on top of prior authorizations, a point that the AMA’s tip sheet emphasizes, saying that it’s important to ensure that requests don’t fall through the cracks.
Given that image tests are often conducted before the patient meets with the doctor, staffers track that authorization’s status well before the appointment itself, Heine says. Thus they organize follow-ups chronologically, focusing on those patients with appointments nearly around the corner.
When the prior authorization backlog begins to stack up at Pho’s practice, a supervisor who serves in a floating role is sometimes asked to pitch in, he says.
Pho also believes primary care doctors are better positioned than specialists to make the case for additional treatment to the insurer, because they tend to assume a more minimalist approach to care.
“Not everybody needs a super-duper acid blocker,” Pho says. “Maybe you need to be on a better diet and stop drinking so much wine and lose some weight.”
But sometimes more costly measures are required, Pho says. He cites the case of a patient who complained about abdominal discomfort along with low-level nausea. She didn’t have any abdominal tenderness that indicated gallstones and she mentioned other factors, such as increased stress, he says.
Pho prescribed an acid reducer, esomeprazole (Nexium) and ordered some blood tests. But when she returned a week later, her upper abdomen was tender and her lab work had identified elevated levels of bilirubin, he says. Pho recommended a CT scan, which diagnosed gallstones. His prior authorization for the scan, submitted with the clinical detail, was approved on the first try.
Pho understands why the approval process exists in some circumstances. But, he adds, “The majority of doctors are smart, good and they try to do the right things. For those that do that, [prior authorization] is probably a nuisance.”