Actions taken to quantify, cut the burdens of prior authorization
Physicians always knew completing prior authorization (PA) requests were a drain on their time and energy. But this year, new survey data helped quantify just how much of a drain they actually were, and a plan of action was developed to tackle the issue.
Survey says: “Burden is high.” A survey conducted in December 2016 helped arm physicians with the data they needed in 2017 to define just how much of a burden PA requests were to their staff and to themselves. Typically, physicians completed an average of 37 PA requests a week, which took 16.4 hours to process, for an annual burden of 853 hours, according to a Web-based survey of 1,000 practicing physicians.
Most PA requests could not be handled electronically and needed to be processed via telephone or fax, which added to the demand on physician and staff time. And too often PA requests are not a one-and-done affair, as 80 percent of physicians participating in the survey reported that they sometimes, often or always are required to repeat the process for stabilized patients being treated for a chronic condition.
Editor's note: This story is part of a new topic hub that centralizes the AMA’s essential tools, resources and content to help you in Navigating the Payment Process. Explore other Medical Topics That Matter.
Rule No. 1: Allow patients to access proper treatment. In an effort to slash administrative burdens, protect patient access to necessary treatments and encourage appropriate management of resources, a set of 21 principles to guide PA and utilization-management (UM) requirements was developed by the AMA and 16 organizations representing physicians, medical groups, hospitals, pharmacists and patients.
“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources and antagonized patients and physicians alike,” former AMA President Andrew W. Gurman, MD, said in a statement.
The 21 principles were divided among five broad categories:
- Clinical validity. UM criteria need to be based on up-to-date clinical criteria and never cost alone.
- Continuity of care. PA requirements must not disrupt patients’ care.
- Transparency and fairness. All coverage restrictions need to be fully disclosed to the public in a searchable, electronic format, and denials must include detailed explanations.
- Timely access and administrative efficiency. There must be a maximum response-time limit for UM decisions, and health plans must accept standardized electronic processing of PA requests.
- Alternatives and exemptions. Health plans should offer alternative, less burdensome approaches to resource management than PA.
Payers, IT vendors recognize need for reform. During the annual Healthcare Information and Management Systems Society’s conference, a multistakeholder discussion on PA revealed agreement across the industry on the need for reform of current processes. A representative of Blue Cross Blue Shield Louisiana described how her organization was working on moving toward electronic, automatic processing and away from needing to make telephone calls and sending faxes.
The Workgroup for Electronic Data Interchange, an organization designed to bring together key stakeholders to improve health care information exchange, noted that it had established a PA workgroup. The group’s goals are “to identify the challenges that electronic prior authorization submitters experience that keep or deter them from submitting the prior-authorization requests electronically” and to “streamline the process to get the decision for prior authorization request to the submitter in as close to real-time as possible.”