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Christina M. Kuta, J.D., LL.M., M.S.W., is of counsel in the Health Law group at Roetzel & Andress in Chicago. She can be reached at 

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 Last year, The American Medical Association released results of their prior authorization survey, which found that physicians were completing an average of 33 prior authorizations per week, waiting an average of two whole business days for approval. The entire approval process had become so burdensome that some respondents reported increasing their staff specifically to deal with the increased burdens of prior authorizations.

We spoke with Paul Joiner, chief operating officer of Availity, to flesh out some of the results from the survey and find out how primary care practices can improve their prior authorization processes.

In case you are new to the concept of prior authorizations, here is a brief explanation from Paul.

 So prior authorization is a process in which providers have to go through on behalf of their patients to get approval from the health plan to provide a service and get paid for it. This process is often reserved for procedures and diagnostics. It's probably the biggest burden in the diagnostic process, just because you're anxious to get to a diagnosis. You'll also hear it referred to as pre certification. And then sometimes there's other confusing topics, like notice of admission sometimes gets called a ‘preauth’, with people technically, because of a common transaction name, but by and large, in general, pre authorization and pre certification is an approval prior to service from the health insurance plan to perform a procedure and get paid for it.

 Paul mentions radiology, but he also said other treatments that typically require prior authorizations are those that require some medical guidelines before administering or performing, including many preventative diagnostic type tests.

Furthermore, they are intertwined with electronic health records, which may present additional hurdles.

 Well, they are because the source of information for supporting the need for the diagnostic test or for that procedure lives within the medical records. So proper documentation and understanding what is needed to attain the authorization is very, very important. It's important from a training perspective. And it's important that this team working on the authorization process is giving that feedback to the physicians, the physician extenders, so the medical assistants, the nurses and the physician assistants, if you will.

 Regarding the report mentioned earlier, Paul says that the average two-day wait time for prior authorization decisions is due to the fact that every health plan handles various authorization types differently.

 Sure, well, every health plan handles various authorization types differently. It takes two days, because one, the sheer volume, and then two, it requires a lot of these requires some type of clinical review and some type of clinical back and forth. And those are limited, expensive, highly skilled, specific resources. And then the back and forth part is, is that many times, there's a level of clinical information that needs to be supplied. And sometimes there's a back and forth conversation that needs to occur before the final disposition of the pre-authorization or the approval or the denial of the authorization can be can be given. And so many times, providers get very frustrated because they're a little confused about the status of the prior authorization, and how plans sometimes struggle to convey that status back to the providers. Obviously the patient's anxious to move on, so it creates a lot of anxiety, but it's a function of resources, the function of the complexity of the process, and in the back and forth conversation sometimes has to occur.

 Also mentioned in the report from the American Medical Association is a reported increase in a sense of burden among respondents. When asked whether or not this burden was perceptual—that it was an incorrect assessment from the physicians—or whether their sense of burden was actually due to requirement changes and increases in complexity, Paul says that it is certainly the latter.

 Requirements are truly been being increased. The level of which, the types of procedures, the variety of procedures, and diagnostic tests that requiring prior authorization is increasing. And then the nature in which these procedures and services are being scrutinized has been ratcheted up.

To the health plans’ credit though, many health plans are trying their best to innovate and improve the process and exchange of clinical information and make it clear to providers on when a prior authorization is required, and information that they need in order to give the prior approval.

You know any recommendation I would give to any provider or any physician especially if they're new to practice or long established, take a second and spend a couple extra moments with your staff and to make sure the process is worked out. And you as a physician know how you can help and how you can provide the proper documentation to facilitate the process or make sure the process is moving. smoothly.

And then the other thing is, is a lot of this misconception going back this 86% of burden increase. There's a lot of misunderstanding between the providers and health plans. And so, if something doesn't make sense, I encourage the providers to reach out to the health plans and have a conversation about it. Because a lot of times, it's a process or a structural issue in terms of how the information is being sent to the health plan, or the way that information is being interpreted creates a lot of confusion, a lot of problem between the providers and health plans, which increases the burden.

I've seen examples where providers have sat down with health plans and worked out and improve the process. And there's always going to be a little friction to the process. But it definitely can be reduced if you just take the time to kind of learn the process, both internally and also engage the health plans.

 Requirements from health plans are not the only way in which requirements, and subsequent physician burden, are increasing. Paul says that there are some legal and regulatory changes that can affect the prior authorization process as well.

 Well, there are in there are different mandates out there trying to improve the process. In fact, I just participated in and testified to Washington organization in relation to the improvement of the process and different operating rules. Core is putting for roles, the AMA is obviously involved. There are other technological advances that will could probably change the authorization process there since the Da Vinci project, which is a clinical information interoperability initiative that's underway. So, there's a lot of pressure from the federal and state governments to improve interoperability to improve the process. Really, where a lot of the technical legal stuff happens is that if you perform a procedure, and the payer denies it, because they don't think proper authorization was in place, that does trigger a formal legal process that does vary from state to state.

 Though some practices said in the American Medical Association report that they were increasing staffing levels to deal with the prior authorization process, Paul says that improvements do not stop at the hiring process.

 Well, yes, staffing. I'm familiar with one practice. You know, a dozen years ago, they had two people working prior authorizations, and now they have eight, it's a practice I'm familiar with. And so, number one thing around when you're increasing staffing is training. So, make sure that you're working hard to evolve your training with the times and staying current corporate policies, and that you're just not perpetuating common myths and workflows that you're constantly improving as you're training your employees.

Number two, invest. Invest in these in these resources that you have in the authorization problem and make sure that are of a high caliber, because there is a valuable payback in terms of them being a sophisticated resource and capable to navigate the system and capital is also capable to, you know, interpret how this process is changing and how the payers are changing.

Next on the process side, you can subdivide the authorization work by payer type, by procedure type, so you can subdivide the work. And that typically helps because then your resources can get more and more specialized and more and more focused in terms of information they're collecting, and who they're communicating with. Because many health plans outsource certain segments of the authorization process to vendors. Radiology benefit managers is a common one, you'll hear where there's an actual health I know speaking with, they're actually speaking a company, who providers provides the UN services or the authorization process to the provider to the health plan. And then providers have to engage the UN vendor. So, from a process perspective, it's about how can you subdivide the work and make sure the work is prioritized and bucket in terms of the most complex the least and make sure the right people working on the right task.

Then from the technology perspective, there's all sorts of opportunity to think through the person trying to attain the authorization and the approval making sure they have all the proper clinical documentation. And then try to understand and engage with that your largest health plans on what tools they have available to you to submit for an authorization or check the status of it. Besides picking up the phone and calling. One thing I want to share that is a common issue that a lot of providers think that they'll go through a solution like you know like Availity has or other vendors have in relation to electronic submission or authorization. I've heard numerous for physician practices say well I also call even if I get an electronic because I want the name and phone number and I want documentation that got called to double check or for an extra level of verification that the authorization is in place because I do not want to denial after treatment. So, despite so what that means is despite electronic channels and technology channels, and integration channels, they're still calling the health plans and trying to write down the name of a call center and the name or name of the time and a reference number for that phone call. So that they have that additional evidence that they did obtain authorization in the event that their claim was denied for that service because prior auth wasn't on file.

Train, hire well, process, constantly review the process, and make sure you're subdividing the work and the technology. Look for all the opportunities you can to pull the practice correct information forward to the process. And that that you're using all the proper available channels to the end of your largest health plans.

 Before we parted, Paul offered some final advice to practices looking to streamline their prior authorization process.

 Well, I hope that they are who are curious, and they go down and try to find the team and staff and they invest a little extra trying time trying to understand how their practice or their facility is managing authorization process and what role they play in that process.

The other thing is that, despite I know, many, many physicians are very frustrated with the authorization process and get upset. And I understand—put those emotions aside and look at it as it is a process it's out there, it's not going away. So with the most open and innovative mine, you can go to the process and see how you can help improve it, or how you can give additional resources or technical resources or integration resources or additional training to make sure your staff is only calling when they have to call and they're using all the best possible tools out there, available to them.

And another thing is, you know, if it is an increasing burden for your organization, keep the Google search up around, you know, authorization tools, because there are some small, innovative companies out there. We're partnering with some and then there are some that we're keeping an eye on that I think are working on trying to come up with little neat little widgets and modules to improve the gathering of the clinical information and the submission of it. And so keep your eyes and ears open because I do think it's a big enough problem that solutions will continue and innovation will continue to evolve the process probably at a more accelerated rate.

Physician's Practice spoke with Paul Joiner, chief operating officer of Availity, to discuss the implications of an American Medical Association survey and find out how you can improve your prior authorization processes.

Improving the prior authorization process

In our last episode, we featured the first part of our Practice Financing discussion with Chris Panebianco, CMO of Bankers Healthcare Group, on loans and credit cards for physician practices.

This week, we continue our practice financing discussion with a focus on patient lending services.

Your ultimate goal as a healthcare provider is to provide the care that you spent years training to perfect.

However, to provide care to all patients rests upon the presumption that patients will be able to pay for services. In an ideal world, this would be the case. But sometimes, some patients present with an ailment that must be treated regardless of the cost; the challenge comes in mitigating the cost responsibility

In these instances, practices can turn to a financial practice called ‘Patient Lending’. It’s similar to loans, except the parties include the patient, the physician or practice, and another third party.

To learn more about this program and how it can help both physicians and patients, we spoke with Banker’s Healthcare Groups President of Patient Lending, Keith Grubele.

What a patient lending program does is it allows patients to have an option—to pay for that-out-of pocket responsibility that in many cases is very affordable for them. So essentially, we provide a specialized financing tool for the patient to be able to afford that deductible coinsurance, whatever that out-of-pocket responsibility is that they may not be able to afford, which unfortunately happens more often than not.

 How patients pay for these services and whom they pay directly varies by vendor or the provider, Grubele says. 

Healthcare providers have taken upon themselves to create some sort of internal payment methods for patients. While it's a very honorable effort, and it's a great idea to do in theory, oftentimes what happens is it divides the practice to where now they have to focus on both being a financial institution and a healthcare provider. That's the last thing we want to do.

I often find that I go into centers and come to realize that there are high paid nurses —their highly skilled nursing staff—which are better suited to obviously provide care to patients. They're now turned into glorified telephone collectors, if you will, where they're calling on patients and saying, “Hey, you know, we gave you a payment plan to be able to afford you out-of-pocket responsibility. You haven't been able to pay it. What can we do here?”

It causes a number of inefficiencies on the back side of the business. The most critical one that we've seen impacting healthcare providers today is larger and larger amounts of patient responsibility or patient AR that sits on their balance sheet. And it goes uncollected oftentimes because our primary goal is to provide care, not to provide a financial lending solution.

So, in many cases, if the provider has internal payment plans, if they've partnered with a vendor, a lot of third party vendors will set up very, very differently. The more successful or the better partner plans for the provider are ones that pay off that patient balance upfront, and that create affordable payment plans through their own platform to the patient.

Essentially, they provide patient with a financing tool through maybe a loan product, that loan proceeds or go directly to the healthcare provider to pay them off, and the patient then engages directly payments with the partner provider.

In part 2 of our discussion with Banker’s Healthcare Group, hear from the President of Patient Lending, Keith Gruebele, on how these programs can benefit your practice by extending the amount of patients that can receive and finance your services.

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