By: Donald Drummy, Director, Revenue Cycle Consulting
As revenue cycle professionals, we often see the burden prior authorizations cause on our patients and providers. I am passionate about making the process easier to get faster patient care access, but I see the scenarios below all too often.
Picture it: Your doctor tells you that you have a life-threatening form of cancer. The treatment needed is expensive, and your insurance requires prior authorization. You, the patient, think, “no big deal, I’ll just have my expensive insurance approve the medicine.” Not so fast. Your insurance requires a “preferred” drug therapy that is less expensive than the therapy your doctor prescribed, which is also known to cause worse side effects and has a more prolonged treatment cycle. Oh, and by the way, it’s because the preferred drug is less expensive.
Well, your doctor can get the better drug therapy approved, but only after a prior authorization request is initiated and denied. Your doctor must appeal via a peer-to-peer review. Your doctor sets up a time to talk with a doctor from the insurance company to discuss why you need to start on the more expensive drug therapy and avoid wasting time on the cheaper drug therapy.
Another example may be that you are a patient experiencing back pain for several months or years! After many months of cortisone shots and physical therapy, your doctor decides a surgical intervention is the best course of therapy. Not so fast, my friend! Your insurance company has denied your prior authorization for that spine surgery and wants you to do another 12 weeks of different physical therapy before you have that surgery.
Prior authorizations have become the bane of existence for patients and providers. However, there are ways to mitigate these denials and obtain a first-pass approval rate of 95%+ for your authorizations. Here are some guaranteed ways to have a successful prior authorization process.
Medical policies for procedures and tests
We know insurance will only pay for medically necessary care, so why not make sure their medical requirements are covered before ordering? Knowing the policy allows physicians to ensure they are “checking all the boxes” regarding insurance requirements for a service to be medically necessary. When possible, it is best to add these requirements into “smart phrases” into your EMR clinical documentation templates.
The list of third-party administrator websites below is not exhaustive and changes over time, but it is a good starting point for your prior authorization team. Most insurance companies use these third-party administrators to manage their prior authorizations for services.
- eviCore: https://www.evicore.com/provider/clinical-guidelines
- AIM Specialty Health: https://aimspecialtyhealth.com/resources/clinical-guidelines/
- TurningPoint: https://www.myturningpoint-healthcare.com/#!/
It is also essential to follow your major insurance payers’ Medical Clinical Policy Bulletins/Announcements for updates on Prior Authorization policies. These updates will often provide information on prior authorization requirements that are critical to your teams.
Use online portals
If you are still faxing prior authorization requests, please investigate to see if you can use web portals. The web portals are faster, and you sometimes get instant approval.
Find a Physician Champion internally
Your prior authorization team will interact daily with clinicians around clinical documentation updates, authorization denials, insurance requests, etc. Providers are stretched thin, and it can be frustrating when revenue cycle colleagues reach out to ask for administrative updates from clinicians or, even worse, give the bad news that the MD cannot move forward with treatment.
An excellent resource to help navigate these difficult conversations is a Physician Advisor (PA) to help explain the prior authorization team’s role in the process of the patient’s access to care. The PA can speak to their peer about the need for an amended clinical note, additional treatment to justify medical necessity for their ordered test/service, or outright explain why the insurance will not cover the treatment they ordered. Removing the patient access team from the conversation allows a clinical perspective to help find a successful path forward for the patient to get the care they need while also having coverage from insurance!
Timing is EVERYTHING
It is critical to initiate authorizations timely to allow time for insurance to make an authorization decision. Generally, insurance companies prefer 10-15 business days to make an authorization decision. Also, insurance typically responds to any urgent requests within 24-48 hours. However, the insurance will only allow urgent requests if the patient’s service is needed because the situation is life-threatening or the patient is at risk of losing a limb.
No one likes to get bad news, especially regarding healthcare. However, it is critical to keep all parties involved in communication when authorization has not been obtained. The patient does not want to get stuck with a hefty bill, and the doctor does not want to find out, last-minute, that their procedure or test was canceled due to no authorization. I recommend having a defined timeline for notification of the provider and patient when authorization is still pending. For example, my team begins notification at 72 hours out and does updates at 48 and 24 hours out.
Communication should include pertinent information from the insurance carrier to the provider and the patient. Also, it is essential to ask the patient to do outreach to the insurance company to ask for an authorization decision. No harm in getting the insurance member (the patient) to put some heat on the insurance to make a decision. Finally, written communication should have a template with all pertinent case information, so your team members have a consistent communication format with internal stakeholders.
In closing, partnering with your providers to identify opportunities using the insurance’s medical policies will help mitigate prior authorization denials. Doing so will help more patients access care faster, creating a positive patient experience.