Part Two:  Independent Healthcare Providers Have a Critical Need for Payer Transparency

 By: Tarah Vanhooser, VP of Ancillary Services at Advantum Health

This three-part blog series explores independent providers’ challenges with payer contracts, fee schedules, and prior authorizations. We also tackle the lack of transparency and accountability and how these issues impact healthcare providers’ business operations. Last month, we shared Part One – The Curious Case of Missing Fee Schedules.  

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Visit any playground with children playing tag, four square, or any other game, and you will learn that rules matter. When kids understand and follow the agreed-upon rules, they have fun, learn to cooperate, and respect their teammates and opponents–winner or not. 

Without simple, clear, and agreed-upon rules, a friendly game of freeze tag can transform quickly into a chaotic wrestling match. 

Unfortunately, navigating the world of prior authorizations can feel like a game with constantly shifting rules, a frustrating experience that many of us can relate to. 

Prior Authorization: A Complex Game for Providers

Part One of this series discussed how payers change the rules, sometimes even excluding fee schedules from contracts. The situation leaves providers with a lose-lose choice: sign incomplete contracts or risk losing significant market share. 

In Part Two, we’re tackling an even thornier topic: prior authorizations.

As long as I’ve worked in the healthcare revenue cycle, prior authorizations have evolved from a minor annoyance to a major roadblock, a wound that never seems to heal. Payers can change the rules mid-game with little to no repercussions, making painful prior authorizations an unfortunate reality for healthcare providers.

Even after providers meticulously follow all the protocols to authorize a medical procedure, payment is never guaranteed. This uncertainty creates an uneven playing field, putting providers at a disadvantage. 

Even with prior authorization, there’s zero guarantee of payment. 

Inconsistent prior authorization processes frustrate providers and patients alike. For instance, an insurance plan may instantly approve one patient’s cardiac rehab therapy while requiring mountains of paperwork for another patient’s treatment plan.

And even worse, payers can suddenly change the rules with little notice. In March 2023, UnitedHealthcare decided that diagnostic and surveillance colonoscopies needed prior authorization, leaving gastroenterologists scrambling. While they eventually backtracked after a considerable outcry, it’s another stark reminder that payers have the upper hand.

There have been times when it felt like our Advantum Health team needed post-graduate degrees in medicine to determine if and when patients would get their procedures authorized and paid.   

I’m hopeful that programs, like UnitedHealthcare’s Gold Card program, will eventually reduce the extra steps and wasted time waiting on prior authorizations, but only time will tell.

Prior authorizations made sense until they didn’t. 

Prior authorizations initially benefited everyone involved: Payers could control costs, providers could ensure medical necessity, and patients could receive appropriate care. It was a system of checks and balances to ensure that providers and patients used healthcare resources wisely.

However, somewhere along the way, the process became overly burdensome, riddled with inconsistencies, and often resulted in delay or denial of necessary care. This shift has left providers and patients feeling frustrated and unheard.

Despite the challenges, I’m optimistic about the future. The increased attention from media and government agencies is a positive sign. It shows that people recognize the current system’s flaws and work towards solutions prioritizing patient care and provider sustainability.

Conclusion 

In the complex world of healthcare, payer contracts can make or break healthcare providers, especially independent physician groups. It’s a high-stakes game where the rules are often stacked against us, and prior authorizations are a prime example of this imbalance.

I remain cautiously optimistic that the situation will improve. Provider and patient advocacy groups are illuminating these unfair practices, paving the way for a more transparent and equitable system. 

By uniting our efforts and demanding payer transparency, we can build a healthcare system that puts patients first. 

Learn more about Advantum Health and how we can partner with you to bring clarity to payer contracts and streamline prior authorizations. Stay tuned for Part Three, where we’ll discuss the challenges of Payers’ “sources of truth.”