The Importance of Prior Authorization and How to Improve Its Process

by | December 17, 2019 | 7:08 am

Prior Authorization (PA) can be a frustrating and time-consuming process. In fact, 86% of physicians describe the administrative burden of prior authorization as high or extremely high.

90% of healthcare providers reported a treatment delay caused by Prior Authorization. Of these, 60% said it took at least one business day to receive a reply, while 26% reported that acceptance was received after three or more business days.

More than 9 in 10 physicians said that the Prior Authorization process delays patient access to necessary care. On average, practices file an average of 29.1 PAs per physicians per week.

Why is Prior Authorization Important?

According to the American Medical Association, “Prior Authorization (PA) is the process by which physicians and other healthcare providers must obtain advance approval from a health insurance plan before a specific procedure, service, device, supply or medication is delivered to the patient in order to qualify for coverage.” Prior Authorization:

  • Helps control costs and manages the possibility of overprescribing.
  • Ensures that the service or drug the physician is requesting is truly medically necessary.
  • Ensures that the service isn’t being duplicated, especially in cases where multiple specialists are involved.
  • Determines whether the ongoing or recurrent service is actually beneficial to the patient’s care.

How to Improve the Prior Authorization Process
1. Automate the Process

88% of Prior Authorizations are conducted either partially or entirely manually, often by phone or fax. This takes hours, days, or even weeks before the request is eventually approved or denied.

Using automated solutions, Prior Authorization can be processed electronically, directly from the provider and payer. The CAQH CORE initiative to standardize electronic Prior Authorization for Medicare Part D plans from Jan 1, 2020, it is set to likely help speed up the electronic Prior Authorization. None the less, to truly improve the PA process requires that you go beyond the electronic Prior Authorizations. Using Automated Prior Authorizations (aPAs) helps expedite the process and improve PA turnaround times by allowing healthcare providers, payers, pharmacies, and manufacturers to be on the same page,  access and share data rather than each working independently and connecting the dots through phone calls, various portals, and reams of paperwork.   

2. Create a Master List of Medications and Procedures

Create an up-to-date master list of the medications and procedures that require Prior Authorization, broken down by insurer, to serve as a quick reference when checking PA requirements. You may use your Electronic Health Record (EHR) database of drug tiers to estimate whether a particular prescription is likely to require prior approval or even ask your largest payers for copies of their Prior Authorization guidelines and drug formulas.

3. Proper Documentation

Proper documentation is the key to an efficient Prior Authorization process improvement. Unusual or poorly documented cases or the use of shortcuts will most likely result in a rejection. Be sure to submit a complete request backed up with well-documented patient data.

4. Minimize Services Requiring PA

Minimize services that require PA to reduce its impact on your practice. Proactively implementing the following allows you and your staff to focus on Prior Authorization process improvement:

  • Check PA requirements before providing services or sending prescriptions to the pharmacy.
  • Establish a protocol to consistently document data required for PA in the medical record.
  • When a PA is inappropriately denied, submit an organized, concise, and well-articulated appeal with supporting clinical information within 72 hours.

5. Hire Prior Authorization Specialists

For most healthcare providers, time is money! Rather than requiring an inexperienced employee to own this activity, consider outsourcing this critical process to a dedicated team of Prior Authorization specialists. Choose medical billing outsourcing to leverage the latest technology and take the stress out of Prior Authorization. It frees your time to stay focused on patients – not paperwork.  

At Analytix solutions, our comprehensive range of medical billing services allow DME and HME providers to outsource all aspects of their medical billing functions or select specific phases to outsource based on needs. Additionally, we are a HIPAA compliant medical billing company. We possess ISO certification for secure data and offer flexible engagement models and payment structures.

Next Steps