Prior Authorizations: 5 Steps to Speed Things Up

Are prior authorizations eating up more and more of your time? This cost-containment measure implemented by insurers drains time and energy from eye care providers and their staff. It also confuses patients, and often conflicts with the best course of treatment.

Unfortunately, the trend of requiring prior authorizations for prescriptions and procedures is only growing more popular.

Prior authorization “creates huge administrative burdens on eye care practices, increasing the cost of delivering healthcare,” says Rhonda Buckholtz, CPC, CPCI, CPMA, CDEO, CRC, CHPSE, COPC, CENTC, CPEDC, CGSC, vice president of strategic development at Eye Care Leaders.

“Prior Auth” Trend Accelerates

The need to get an increasing number of prescriptions and procedures approved before treatment is a familiar frustration for doctors. “Years ago, it hardly ever came up,” says Buckholtz, who has more than 20 years experience in healthcare reimbursement, billing, and coding. “Then we started seeing it in a small number of high-dollar, brand name drugs. Then, it expanded into even more medications—along with utilization requirements. Now, many procedures require a prior authorization or at the very least a notification to the payer.”

You Are Not Alone

If it feels like you’re the only physician or practice manager who spends more and more of your day on the phone justifying procedures and medications, rest assured: you’re not alone. In 2016, the American Medical Association conducted a survey of member physicians to assess their prior authorization experience.

The results were striking: A full 75% of respondents called their administrative burden high. No wonder, when they averaged 37 prior authorization requests per week. They also estimated 16 hours spent weekly on those requests. As a result, one third of the physicians hired a staff member whose only job was handling prior authorizations.

“Because of the number of things that authorizations are being required for, I know an eight-doctor group that has a staff member who spends 80% of her time just doing prior authorization for tests,” Jill Young of Young Medical Consulting told Practice Management Alert.

An added frustration: Increasing payer requirements don’t come with better payer personnel. “It’s hard enough for the doctors’ offices to find people who know what they’re doing,” says Young. “But for the insurance companies to find experienced people is almost impossible. So often the person you’re talking to at the insurance company just has a script for prior authorization, and if you go outside the script, he doesn’t know what to do.”

Cut Through the Clutter Of Prior Authorizations

Despite the pain of prior authorization, your practice can take concrete steps to make the process more efficient.These five strategies will save you time—and your sanity.

1. Put the right person in charge.

“Don’t have your least experienced person handle prior authorization,” warns Young. “He or she has to be savvy.” It isn’t a task for your newest employee, even if it might seem like mindless work at times. An experienced hand can drastically speed up prior authorization.

2. Embrace newer technology.

Many prior authorizations are still done by telephone or fax, even as more and more business is conducted online. Whenever possible, says California-based medical consultant Judy Bee, use the payer’s website for all prior authorization requests. This completely eliminates the dreaded wait time on hold that is the bane of every medical practice. Even if using the online option only slightly reduces the time needed to hear back from an insurer, it saves hours of dead time on the telephone. (Hint: Ophthalmology EMR software has evolved to help with these tasks, too!)

3. Reassess your payers.

A more drastic step calls for cutting out troublesome insurers entirely. “If you have a plan that is ho-hum in its reimbursement and is requiring a lot of time (to approve prior authorizations), you probably should rethink whether you need to participate, because that’s coming right out of your wallet,” says Bee. The best ophthalmology clinic software can help you to determine which insurers demand the most prior authorizations (or take the longest to respond to your requests). It might make more sense to stop accepting those plans than to deal with the headaches they create.

4. Centralize staffing.

If your practice contains multiple offices or locations, you might be able to take advantage of your scale. Designate an employee or two to handle all prior authorizations. This centralized system will help you cut down on redundant staffing, says consultant Owen Dahl. Also, your prior authorization staffers will get to know the insurers well and become true experts in this difficult process.

5. Negotiate

You may be able to work out special pre-approval deals with insurers to circumvent prior authorization. “Tell the payer that if the patient presents with this disease, this is what we will do,” Dahl recommends. “Can we get blanket approval for this without having to call every time for authorization if the patient needs a procedure under this treatment plan?” Creating condition-specific plans of care in advance lets you do what you do best: treating your patients, not waiting for the go-ahead from a far-off insurer.