Top challenges of 2022, No. 3: Prior authorizations

Medical Economics Journal, Medical Economics January 2022, Volume 99, Issue 1

Editor's Note: The past year has been one of the most challenging on record for U.S. physicians. After the lockdowns and telehealth surge of 2020, the year 2021 has been strange. Although things went back to “normal” in that most practices resumed seeing patients in person, the COVID-19 pandemic and its challenges remain. As we do each year, Medical Economics® surveyed our audience to find out what the big challenges were. By far, the top answer was “administrative burdens” including staffing, prior authorizations and electronic health records (EHRs). We decided to take a closer look at what these burdens entail, to help physicians get ready for whatever challenges 2022 will bring. Here's number three.

Doctors want to treat patients using the care they were trained to give but often find themselves arguing with someone from an insurance company about what the best course of treatment is. This is the main reason physicians consistently rank third-party interference as one of their biggest challenges.

“The problem with a lot of insurance companies is they change what’s on their formularies, and one day the insulin NovoLog is covered and then next day it changes to Humalog, and now the patient has to switch and it’s very confusing. And if you want to keep them on the same one, you have to put in the prior authorization, and the insurance company wants them to try the other one first,” says Richard Bryce, D.O., a family medicine physician and chief medical officer for the Community Health and Social Services Center in Detroit.

This back-and-forth costs the practice time and money and puts the patient’s health at risk.

“Now you’ve wasted a week or two figuring this process out when a patient needed the medication to take care of their ailment,” Bryce says. “The process should be easier.”

Although prior authorizations aren’t going away, there are some strategies practices can use to streamline the process.

  • Assign a staff member to each payer. This person can become an expert on the payers for which they are responsible, learning their specific expectations and what to avoid. They can also build relationships with their counterparts at the payer, which may help expedite claims and appeals. This person should also create a basic guidebook for each payer that others can follow if needed.
  • Maximize the use of technology. Most payers offer online forms for the prior authorization process and some EHRs integrate directly with payer formularies. The more a practice can use these online forms, the more quickly an authorization can be obtained. In many cases, any missing information will be flagged before submission.
  • Document all treatment decisions and back them up with evidence-based practices. Payer justification for prior authorizations is that physicians are not always following the latest evidence-based practices, so ensure all treatment decisions are based on the latest guidelines. If a prescription is not following the formulary, make sure all information as to why it is not is included in the prior authorization form.
  • Prepopulate forms for each payer. In some cases, you may be able to create a prepopulated form that has common information from the practice already filled in. This just leaves the specific patient information to be added. Although the time savings may be small for each form, it can add up when multiplied over the course of a year.
  • Create a spreadsheet outlining what treatments and medications for frequent diagnoses require a prior authorization by payer and what the permitted alternatives are. This quick-reference guide can save physicians time by directing them toward treatments the insurance company will accept.
  • Inquire about gold card programs. Some payers offer physicians with a good track record of following clinical best practices a gold card that allows them to skip the prior authorization process for some treatments. Find out whether you are eligible and what it takes to earn eligibility.
  • Fight to get rid of the prior authorization burden. Most professional medical societies have come out against prior authorizations and are pushing for legislation to limit their use. Check with your organization to find out how you can help. Write to your state and federal representatives and explain how the process harms patient care and raises health care costs.