Industry improvements to prior authorizations

October 7, 2020

While providers have many legitimate concerns about the PA process, it remains an important tool to help ensure that the care patients obtain is safe, effective, and necessary.

Given the nature of the prior authorizations process, it’s inevitable this practice will lead to some level of provider abrasion; however, the healthcare industry is taking steps to reduce the burden prior authorizations create.

From the provider’s perspective, prior authorization (PA) often represents a series of unnecessary, manual steps that encumber workflows, reduce the ability to focus on the Triple Aim (better care, lower costs and patient satisfaction) and end up sowing distrustful relationships with payers.

A 2019 American Medical Association survey of 1,000 practicing physicians reveals providers’ level of dissatisfaction with PA. In this survey, 91% of physicians reported that the PA process delays necessary care, 64% reported waiting one business day on average for decisions from health plans, and 24% said PA has led to serious adverse events for a patient in their care. Payers also acknowledge that the PA process is far from perfect and does create burdens for providers and their patients.

Problems with prior authorization
Payers and providers agree that inefficiencies associated with PA have the potential to delay important patient care and drive up costs. This occurs for a few reasons:

  • Uncertainty about requirements: Although many procedures do not require PA, provider staff often check anyway, just to be safe. The average provider may contract with dozens of health plans—each with its own policies and procedures—which leads to confusion about whether PA is even necessary. If payer documentation regarding PA is available, it is time-consuming for staff to consult and may not be up to date.
  • Confusion about where to submit: Health plans often partner with utilization management vendors to expedite clinical review; however, this situation may lead to provider confusion about where to submit PA requests. A staff member may submit a PA request to the health plan, only to discover days later that they should have sent it to the utilization management vendor.
  • Too much mailing and faxing: A major component of the PA process is clinical review, where payers evaluate the medical necessity of a procedure ordered by a provider. When providers submit clinical records to payers during clinical review, they do so via fax or mail, which results in delayed care.
  • The mystery of status: Front-office staff must carefully track PAs against patient rosters to ensure the practice receives an answer prior to the patient's visit or procedure. Without a convenient, user-friendly way to stay updated, staff sometimes resort to spreadsheets and sticky notes. 

What the industry is doing to make it better
Payers are developing specific programs aimed at promoting safe, timely, and affordable access to evidence-based care for patients, to enhance efficiency, and reduce the administrative burdens of PA. Payers and their health information technology partners have worked to reduce provider abrasion, administrative overhead, unnecessary touch points, and delays to care by alleviating many of these issues. Many payers have already put these goals into action by taking steps to automate, simplify, and enhance process transparency. Two examples of these efforts are:

  1. Multi-payer portals: Multi-payer platforms are centralized portals that enable providers and plans to exchange and reconcile data. By using a single platform for providers to update and manage data—including PAs—for all their contracted health plans, payers and providers can streamline processes and achieve better data quality and accuracy. Multi-payer portals can alert providers when payers approve PA requests, or, alternatively, can be used to send electronic attachments to payers when further review is needed.
  2. Real-time verification: In many cases, a PA is not required for a procedure, and payers can reduce provider administrative time by allowing them to determine in real-time if one is necessary before they start the process. With leading PA technology, providers can query whether an authorization is needed by entering a few simple data elements—such as group number, procedure code, and date of service. The query runs against the payer’s prior authorization rules engine and returns an immediate response. 

While providers have many legitimate concerns about the PA process, it remains an important tool to help ensure that the care patients obtain is safe, effective, and necessary. Nonetheless, providers’ PA pain is real, so payers and their IT partners must ensure that the costs of the process are commensurate with their benefits. While it’s unrealistic to expect that provider abrasion resulting from PAs will ever disappear completely, the industry will continue to work to reduce the pain as much as possible.


About the Author

Melissa Gaffney is the Director, Clinical Solutions and Strategy for Availity, the nation’s largest health information network.