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.
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.