Prior authorization is used by health insurance companies to determine whether they will cover a prescribed procedure, service, or medication for a patient. The debate surrounding the prior authorization process has been ongoing for quite some time in the healthcare industry. It is a hot topic, and like any other healthcare process or procedure, prior authorization has its pros and cons. The typical process is that a prescriber must complete a form to explain why a particular medication to treat a specific condition has been prescribed to a patient and why it is medically necessary for their treatment plan. This process can be a time-consuming initiative to prescribers, but there are ways to help manage the administrative burden of prior authorization.
Prior Authorization Requirements Needs
The process of obtaining prior authorization creates a significant burden for healthcare providers. Physicians have criticized the process as being time-consuming and expensive for their practices. According to a Medical Group Management Association (MGMA) survey, there was a steady rise in prior authorization requirements in 2018. Also, 87% of survey participants said the prior authorization burden has increased in the last five years.
82% of providers cited the pre-approval process as their top regulatory burden during that year. According to respondents, numerous prescription drugs and an increasing number of procedures need prior authorization, which has led to increased staff time and an increase in the number of resources spent on meeting health plan mandates. In addition, third-party companies involved in the health plan’s utilization management procedures made the process more time-consuming, leading to a need to hire extra staff to keep up with the requests, which subsequently affected patient care while also delaying treatment.
Several recommendations have been made by the Medical Group Management Association (MGMA) to work towards three main goals to manage the administrative burden of prior authorization:
- Reduce the overall volume of prior authorization requirements
- Improve health plan requirement transparency
- Evaluate areas to automate prior authorization transactions
Automate Prior Authorizations
Automating the process and proactively checking requirements for prior authorizations while engaging staff to focus on prior approvals can help providers deal with the burden that comes with prior authorizations.
According to the 2019 Council for Affordable Quality Healthcare Index, only 13% of prior authorization transactions were automated. A shift to automated prior authorization would increase efficiency in the process and prevent errors. Fully automated prior authorizations will also save time and money.
The majority of health plan denials and underpayments can be attributed to prior authorizations, eligibility rules, and medical necessity requirements. The automation of prior approval at the point of the physician’s order or referral is critical to eliminate this issue. The administrative costs related to the manual prior authorization process adds up to about one-third of the physician’s compensation. If possible, providers can automate their prior authorization by implementing electronic prior authorization technology.
Electronic ingestion of orders and running unique rules immediately in real-time are vital functions that automation technology should do. Appropriate implementation of technology will enable reliable completion of a substantial portion of prior authorizations. High-cost modalities such as surgeries need an automated process that uses the required payer data to determine the prior authorization decision before submitting the information to the plan. If authorized, the scheduling process can then be done on a highly automated basis, resulting in the patient being seen and not rescheduled due to a lack of authorization clearance.
Dedicated Professionals to Assist with Prior Authorizations
Prior authorizations come with many administrative burdens that can overwhelm the physicians and other care delivery providers. Providers can shift the responsibility of prior authorizations to dedicated staff and increase productivity. Using certified pharmacy technicians for prior authorizations could save quite a bit of time.
Confirming Prior Authorization Requirements
Checking prior authorization requirements before sending prescriptions is essential to manage some of the admin of this process. Most health plans would not disburse money for services if prior authorization was not correctly done before treatment. CAQH recently reported that prior authorization accounts for only 2% of overall medical transactions, but it is the most costly and time-consuming transaction to family physicians. It is time to reduce the prior authorization burden to physicians.
At Orsini Specialty Pharmacy, you can count on us to help expedite the completion of insurance paperwork required for approval and appeal support. Proactive notification and assistance when reauthorizations are necessary to ensure no interruptions in therapy for the patient. This process enables you to spend less time on paperwork and more time with your patients. Learn more about how Orsini supports our specialty pharmacy prescribers.v