By Lola Koktysh

Healthcare has plenty of problems to juggle, and prior authorization (PA) is the one to stay.

As if relations within the trio of patients, payers and providers weren’t complex enough to regularly require specific consulting, there’s always a new regulation or requirement to entangle them even more.

This time, prior authorization (PA) is on the agenda. Also called preauthorization, precertification, etc., this is a requirement to get the payer’s approval on applying a particular procedure, treatment plan, prescription medication or durable medical equipment. While it is destined to help providers control healthcare costs and benefit value-based care in the long run, in reality it is a formalistic time-eater for everybody.

Wishful thinking under prior authorization…

Same as literally every regulation, PA was designed with a good intention – to allow payers and providers gain a better control over healthcare costs. Balanced costs, in their turn, should help providers to hit the performance benchmarks while keeping care quality high. Practically, this is everything that the value-based care environment stands for, and any ACO model aims at.

Due to the intention to cut costs, payers increase their use of prior authorizations related to more expensive treatment, and especially when the therapy is complicated or its appropriateness is questioned (such as retest).

The nation’s changing demographic is also playing a role. More patients become eligible for coverage under Medicare and Medicaid, which also leads to increased treatment costs. Accordingly, payers have to push prior authorizations to keep financials in hand.

…Gone wrong

The PA process can include a number of steps, such as finding the appropriate form, filling it out, appending information with clinical documentation in certain instances and submitting the form to the payer. Sometimes providers also have to fill out and submit a follow-up form as well. Payers can often require additional information and even a resubmission of the second form.

If the caregiver needs to call the payer for consulting, clarification or to follow up on a submitted request, the hold time can last 20+ minutes. Overall, the whole process can take 30-45 minutes for each PA submission.

With all the steps and waiting time, the PA process turns out to be a complex and frustrating experience, highly disruptive to workflows. It delays needed care and poses additional administrative burden.

Currently, a regular practice spends about 32 hours per week on handling prior authorizations, with more weekly authorization requests by between 40% and 50% compared to 2014. And the trend is on the rise. For example, the 2015 Kaiser Family Foundation analysis of Medicare data found that 23% of medications covered by Medicare Part D required prior authorizations, up from 8% in 2007.

Accordingly, providers will spend even more time to process PA requests in the future. Given that the forms can be complex and are frequently amended, it’s no surprise that some caregivers may give up on previously chosen treatment plans even if they believe that the original therapy is better for their patients.

How technology can streamline PA

There isn’t much that caregivers can do to foster the PA evolution and growth, yet they can adopt technology to manage the situation instead of dropping required procedures and medications. When chosen right, software will allow automating the major part of the PA process when it comes to choosing appropriate forms, partial submission and status tracking.

The question of choice is on the table because of the end users, aka health specialists. Being a longstanding healthcare IT consultant, never have we ever encountered the specialists happy to dive in the new technology. They are already exhausted enough with current workflows and existing software to think about one more application with forthcoming training and adaptation stages. So, the solution should be naturally bound to a familiar system, say, EHR.

While the current EHR systems evolve into full-cycle practice management applications, they still don’t offer any PA support. Customizing an EHR can be a time- and budget-consuming decision, let alone the probability of the EHR vendor saying no to the idea. On the other hand, providers can invest into a PA-processing application and its integration with the EHR.

Such an application can allow specialists to work with PA requests in a familiar environment, getting only up-to-date forms, submitting them in the app, sending and tracking the progress. No calls and hold times, and the payer’s answer can be anticipated within 48 hours. As soon as the request status changes, health specialists can get notifications.

Using PA painkillers wisely

Of course there’s no silver bullets for handling prior authorization processes. But doing nothing about the rising percentage of approval-required medications and procedures is also a path to nowhere. Instead, providers can reduce most of the PA pain with the help of technology. Not all of it, but this way caregivers can at least withstand those inevitably growing piles of requests instead of being buried under them.

Top it off, a gradual transition into the value-based care environment can at some point lead to incorporating prior authorization into patient health outcomes measures. So, prior authorization is here to stay and to grow anyway, and the more effectively providers handle it, the better they can be at providing patients with intended care.

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