Electronic Health Reporter

Guest post by Saqib Ayaz, co-founder, Workflow Management & Optimization.

Have you ever faced the dilemma when you visited a hospital or a pharmacy and have been told that the impending treatment or even the prescription will need a prior authorization?

Prior authorization has been a topic of debate in the healthcare industry for quite some time and it is important to understand the process in detail to be able to take the informed decision when required.

What is Prior Authorization in the healthcare sector?

Healthcare industry, in general, is quite complex in nature with a large number of standard rules and procedures to be followed. The concept of prior authorization or pre-authorization as it is commonly called is generally used during the payment from the insurance partner.

Prior authorization in the medical industry is an intermediary step mandated by the insurance partner that requires an approval from the insurance company in order to take a decision on whether they will/will not reimburse the cost of a certain treatment/prescription/medicine. To put in simple words, healthcare prior authorization is a health plan cost-control process that requires obtaining approval before performing a service to qualify for payment.

Important points regarding prior authorization

• The concept doesn’t affect the cash transactions for prescriptions/ treatment
• Prior authorization is only required by the insurance partner on those prescriptions when the medical billing is done through insurance.
• Anyone who is uninsured or is willing to do the cash transactions, there is no need for getting any kind of prior authorization.
• In normal circumstances, the prior authorization is required for pharmaceuticals, medical services, and durable medical equipment

Prior authorization predicament

Like any other process, there are pros and cons of the prior authorization process as well. While the process brings a certain accountability and cost containment for the players; fighting over prior authorizations costs several hours in lost productivity and an incredible amount lost in revenues as well, thus putting everyone in a difficult position.

The American Medical Association (AMA) along with the other stakeholders from the healthcare industry believes that prior authorization is actually a burdensome process that hinders the productivity and also timely access to treatment. The process puts a barrier for the patients in immediate need of the medical care by delaying the start of the necessary treatment/medical assistance required by the patient that can significantly impact the health outcomes.

The Current Reality

A recent survey conducted by the American Medical Association (AMA) reveals certain shocking findings:

• Approximately 75 percent of the physicians who were the part of the survey described prior authorization burdens as high or extremely high.
• Approximately 60 percent of physicians who participated in the survey reported that their practices wait for minimum of one business day to maximum three business days for prior authorization decisions on an average.
• Approximately a third of physicians who were part of the survey raised concerns over man power inefficiency with staff who works exclusively on prior authorization requests.
• Approximately 90 percent of physicians who participated in the survey reported that the prior authorization process often or always delays access to medical care to the patients

What are the disadvantages of the Prior Authorization process?

• The process is time consuming, inefficient and lacks the transparency, which is crucial for the patients.
• Disrupts the workflow of the medical facilities and the process of providing the quality care to the patients in need.
• The processing of the prior authorization wastes a great deal of physicians’ or medical practitioners’ time that would be better spent with the patients and for the treatment.

The Road Ahead

Considering the inefficiency of the process of prior authorization and the various hurdles the patients seeking medical care faces, the American Medical Association (AMA) along with a group of experts from other medical and healthcare organizations came together in an effort to reform the inefficient prior authorization requirements imposed on the patients during the medical tests, devices, drugs, prescription and etc.

Purpose of the AMA and other medical organization coalition

The main purpose of the coalition represented by the hospitals, patients, medical group, pharmacists and physicians, is to make the process of pre-authorization simpler, faster and smoother.

The joint forum believes that the requirement of the pre-approval by insurers in the form of pre-authorization before patients can get the prescribed drugs or treatments can not only delay or interrupt medical services, but also poses the risk of medical complications due to delays in the process.

The group is propagating an industry-wide reassessment of the prior authorization process to align with a newly created set of 21 principles. The main concepts which will form the foundation of these principles are:

• Continuity of medical care and clinical validity
• Efficiency and transparency in the process
• Timely access to the medical care
• Considering the alternatives and exemptions

Tips to make the prior authorization process more efficient

AMA in consultation with other medical fraternity experts suggested several ways to make the process of prior authorization more efficient to lessen its impact on the patient care. Some of these suggestions are discussed below:

• Efficient logistics management: It is suggested to check the detailed prior authorization requirements before providing services or sending the prescriptions to the pharmacy. This will ensure that the time taken in filling prescriptions, managing the claim denials, and other such logistical hiccups can be dealt efficiently.
• Following a set protocol: One of the other significant steps to manage the prior authorization process efficiently, as suggested by the AMA, is by establishing and following a strict protocol of consistently documenting the data, the availability of the entire information etc. By maintaining uniformity in the protocol the delays in the treatment of the patient can be avoided significantly.
• Strict follow-up to ensure timely approvals: One of the challenges of prior authorizations is the manual nature of the process that takes multiple steps to solve a particular query thus wasting a lot of time. The AMA suggests tracking of the prior authorization requests rigorously and following them up to prevent any kind delays in the process.
• Efficient management of the claim denial requests: To prevent further delays in the timely medical care, it is essential to manage the claim denials efficiently. It is suggested that when a prior authorization request is inappropriately denied, put together an organized, well-articulated, and organized report supported by the appropriate clinical information to speed up the process.
• Choosing the most appropriate prior authorization method: There are a number of prior authorization methods available these days such as standard electronic transactions, health plan portals, telephone, secure email etc. AMA along with the expert medical practitioners released a comprehensive pre-authorization toolkit that gives the details of the pros and cons of each method to help the medical facilities take an informed decision.