Many medical practices spend an excessive amount of time on prior authorization (PA), dedicating countless hours that could have been geared toward patient care instead to manually inputting data. According to the American Medical Association (AMA), this can result in delayed treatment, leading to negative clinical outcomes. Hoping to decrease the burden that PA puts on both physicians and patients, the AMA has been working to obtain a scaled-back, streamlined, automated PA process. However, this will take time.
In the meantime, physicians must function within the current PA process, in which insurers usually reply to PA requests in 5 to 10 business days with approval, denial, a request for additional information, or a recommendation with less expensive options. According to medical writer Dr. Naveed Saleh, MD, MS, physicians should note that their input is a significant factor in the insurer’s decision-making. PA approval is of benefit to patients for many reasons. Insurer Cigna claims that in requiring an attempt at lower-cost options first, PA results in lower treatment costs. In addition, Cigna suggests that PA lessens the use of unnecessary treatments or addictive medications.
Include Any Necessary PA-Required Documentation in Patient’s Chart
Therefore, it is in a physician’s best interest to employ certain strategies aimed at obtaining PA approval. For example, the AMA suggests that physicians review PA requirements prior to treating patients. This both aids in thwarting denials and in minimizing prescription delays. It would also behoove physicians to include any necessary PA-required documentation in a patient’s chart, thereby minimizing the physician’s involvement and allowing other staff members to work on the PA. The AMA also suggests that physicians follow up with insurers to confirm both receipt and timing of the PA request. Should an insurer deny a PA, physicians should take care to submit organized, succinct appeals.
According to a Family Practice Management (FPM) blog, other strategies for obtaining PA approval include creating master lists of medications and interventions that necessitate PA, filtered by insurer, as well as programming the EHR system to flag anything that may warrant PA. Employing pre-populated forms and delegating certain staff as PA-handling “experts” offer some options for streamlining the PA process. FPM also suggests strategies like prescribing generic drugs, which typically do not necessitate PA. In the case of a denial, physicians should stand by their request by submitting letters that provide evidence of a patient’s need for specific medications and how their absence could prove dangerous for the patient.
