Grow your practice by optimizing your prior authorization process

July 1, 2020

Unfortunately for physicians, payers continue to demand prior authorization for more care items.

The complex, highly manual prior authorization (PA) system continues to frustrate clinicians, negatively impact patients, and cost practices huge sums of money. The PA process causes frequent delays in care, often at the expense of patient health.

Technology is a significant part of the problem, despite years of efforts to streamline systems and speed up processes. A lack of coherent electronic systems has some practices resorting to paper faxing while others struggle to submit documents to multiple health plans’ proprietary web portals. As health plans add more drugs, procedures, and medical equipment to the long list of items requiring prior authorization, many practices have been forced to hire staff dedicated entirely to submitting and tracking requests.

One of the first attempts at fixing the PA system was based on the HIPAA Healthcare Service Review X12-278 transaction standard. Unfortunately, the protocol wasn’t robust enough to support all of the detailed clinical data necessary for PA.

More recent streamlining efforts involve the Fast Healthcare Interoperability Resources (FHIR) standard, which is based on HL7 v2. FHIR combines the best features of HL7 v2, HL7 v3, and Clinical Document Architecture (CDA), while leveraging the latest web service technologies. The design of FHIR is based on RESTful web services–a contrast to the majority of IHE profiles which are based on SOAP web services. FHIR supports information exchange via mobile phone apps, cloud communications, EHR-based data sharing, and server communications. The Office of the National Coordinator for Health Information’s (ONC) Cures Act Final Rule calls for open APIs (application program interfaces) to be certified.

The industry seems to be coalescing around FHIR-based APIs, but how widespread the adoption will be is hard to predict. And although the major EHRs will likely adopt these standards quickly, smaller practices not using a certified EHR may have to wait months or years.

Best practices improve the PA process

There are four best practices physician groups can implement as they wait for improved integration. All aim to lower PA-associated costs and shorten the time patients must wait for approvals.

  • Deepen your knowledge of payer policies. It’s not possible to have updated information on the PA-related policies for every health plan you work with. But it is possible to create clinician guides for the insurers you work with most frequently. If you limit the guide to the prescriptions, medical devices, and procedures your practice routinely recommends, the task is achievable. The guide should:
    • Inform clinicians about care recommendations that necessitate a PA
    • List the clinical documentation required by the health plan for approval of each care item.

Follow evidence-based guidelines to reduce denials

Standardizing on widely agreed upon clinical guidelines for all/most procedures and care recommendations speeds up the PA process and decreases denials. This is a three-pronged effort. First, decide if you’ll develop your own set of guidelines using a resource such as the National Guideline Clearinghouse or purchase them. Second, create a program to inform all clinicians about the guidelines to be used and the benefits of using them. Third, outline the steps needed when deviating from the standards (i.e., if the standard of care for knee surgery is X rehab days and your patient’s condition necessitates X+10 rehab days, what additional documentation will be required).

Discuss options for reducing PA volume with your main payers

Some payers are allowing PA exceptions for certain patients, such as those with multiple co-morbidities or who need a repeat procedure. Other payers are allowing physicians with proven patient-care track records or who are participating in risk-based payment contracts to bypass the PA process. Another option is bundled authorization for certain procedures, medications, or medical equipment for practices participating in alternative payment models.

Rely on cloud-based solutions

Practices waiting for EHR-based PA technology may want to consider a cloud fax solution. A majority of physicians use phone or fax as the primary method of requesting PAs, so cloud faxing is a natural next step. More secure than traditional fax, cloud fax technology lets users quickly send email messages with attachments (e.g., clinical documentation) to other digital and physical faxes.

The pain caused by the current PA system is very real for both physicians and patients. The AMA’s Prior Authorization Physician Survey found that 44 percent said the PA process “sometimes” leads to care delays, and another 36% said it “often” does so. Almost 30 percent reported that the PA process has led to a serious adverse event for a patient.

A whopping 86 percent of physicians said they’d describe the burden associated with PA as “high or extremely high.” Slightly more than 35 percent said they have staff who work exclusively on PA, and the average number of PAs completed per physician per week in 2018 was 31.

For many physicians in small practices or rural areas, the discussions about HL7 and FHIR standards are nothing more than noise in their daily efforts to get patients the care they need in a timely manner. Indeed, the long battle between physicians and payers over the best way to get patients the care they need is raging hotter than ever, despite decades of effort to come together to create a solution.

Unfortunately for physicians, payers continue to demand prior authorization for more care items: 50 percent of physicians said their PA burden has increased significantly in the last five years.

The best practices described above are strong steps in easing that burden, allowing clinicians to spend less time on paperwork and more time with patients, as well as freeing up resources currently dedicated to the PA process to allow your business to grow.

About the Author

Brenda Hopkins is the Chief Health Information Officer for J2 Cloud Services. She specializes in the area of healthcare interoperability where she is focused on open data exchange of healthcare information inside and outside of the EHR and using open platforms and tools such as APIs as a means of sharing.