Prior authorization of healthcare procedures is critical to payer efforts to control costs and ensure patient safety and compliance. From the provider perspective, however, prior approval is often viewed as a necessary evil fraught with administrative burden.

In a 2017 study conducted by the American Medical Association, 84 percent of survey participants described the burden of prior authorization on physicians and staff as high or extremely high. Other studies suggest that physicians spend an average of 20 hours per week and nearly $83,000 per year interacting with insurance plans. With the prevalence of prior authorization requirements on the rise, these numbers will continue to climb.

The good news for providers is that, as the healthcare industry moves to value-based payment models, we should eventually be able to expect a reduction in prior authorization requirements or a shift to an alternative prior authorization program. Some of these alternatives include:

  • Prior Authorization Sunset Programs – Prior authorization requirements would be removed for services with universally high approval rates.
  • Gold Card Programs – Providers with high rates of approvals over a given time would be exempt from future prior authorization requirements.
  • Prior Authorization Waivers – Providers using approved and clinically-based appropriate use criteria and clinical decision support would be excluded from prior authorization programs.

Until major prior authorization reform occurs in the healthcare industry though, providers will still need to follow the requirements set forth by payers. Here are six steps provider organizations can put in place today to streamline the prior approval process.

  1. Know what’s required. Always check authorization requirements prior to rendering care, particularly for procedural and surgical services. Review and utilize available payer coverage determination guidelines and/or medical policy guidelines to proactively submit necessary information on the first attempt.
  2. Streamline your processes. Focus immediate efforts on the top 10 to 15 payers. Build informational summaries (specific requirements, preferred means of contact, etc.) for each that are easily accessible to staff. Use a simple spreadsheet to track your prior authorization submissions and associated results.
  3. Leverage your resources. Develop and adopt EHR clinical templates specific to payers and procedures that facilitate appropriate capture of the required clinical documentation guidelines necessary for approval. If available, use ASC X12 278 Health Care Services Request functionality to submit and receive results of prior authorization requests.
  4. Play it smart. Submit prior authorization requests and supporting documentation appropriately. Submit what is required and nothing more. Date and time stamp all submissions. Institute formal follow-up policies, timelines and procedures. Develop and maintain standard letters of appeal for use in the event of denial.
  5. Review and analyze prior authorization tracking information to better understand what types of care post risk of denial, segmented by payer. Identify any differences between staff approval rates. Implement operational changes building best practices around successful submissions.
  6. Communicate and educate. Facilitate periodic meetings with staff and providers to open a forum regarding prior authorizations. Preemptively evaluate primary and alternative plans of care in consideration of potential delays caused by services with explicit prior authorization requirements. Keep payer profiles updated regularly to ensure continued success.

By adhering to these best practices, healthcare organizations can bring efficiency to the prior authorization process and diminish the burden to clinicians and staff. These steps also reduce the threat of patient care delays, operational roadblocks and denials.

Contact us to learn how Advantum Health can help simplify your prior authorization process.