Prior authorization is a major practice burden. How do you compare?

Andis Robeznieks
Senior Staff Writer
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Medical practices spend an average of two business days a week per physician to comply with health plans’ inefficient and overused prior-authorization (PA) protocols. One-third of practices employ staffers who spend every second of their working hours on PA requests and follow-ups.

Like sands through the hourglass, so are the days of prior authorization.

These figures come from the responses to a 27-question, web-based AMA survey administered to 1,000 American physicians who provide at least 20 hours of patient care per week. The toll of prior authorization is rising, they said.


This story is part of the AMA’s Advocating for Patients and Physicians topic hub. Explore other Medical Topics That Matter.


Nearly 90 percent of the physicians reported that the administrative burden related to PA requests has risen in the last five years, with most saying it has “increased significantly.”

Jack Resneck Jr., MD, a health policy expert and professor of dermatology at the University of California, San Francisco, said the survey results reflect the dismaying reality that now delays doctors’ orders for even routine prescriptions.

“Physicians have, for many years, expected to face prior-authorization hurdles for a few new or unusually expensive medications or tests. But, more recently, insurers have rapidly added PA requirements to more and more treatments,” Dr. Resneck, chair-elect of the AMA Board of Trustees, told AMA Wire®. “This survey demonstrates the increasing burden.”

On average, a medical practice will complete 29.1 PA requests per physician per week that take 14.6 hours to process. About half of the requests are for medical services, while the other half are for prescriptions, the survey found.

“In my own practice, I now get insurer rejections or PA demands for a majority of the prescriptions I write each day—even for many generic medications that have existed for decades,” Dr. Resneck said.  “For many conditions I see, even when there are several treatment options, I increasingly run into plans where every single one of those choices requires a PA.”

Dr. Resneck’s experience is the new normal.

Seventy-nine percent of the physicians surveyed reported that they sometimes, often or always are required to repeat the PA process for prescription medications when a patient is stabilized on a treatment regimen for a chronic condition.

“While most of these PA requests ultimately get approved, the time my staff and I spend filling out lengthy forms and calling health plans to appeal is substantial—and those are hours I am unable to spend face to face with patients,” Dr. Resneck said.  “My practice has several medical assistants who spend countless hours helping our physicians on PAs each week.”

Unmerry-go-round

Almost two-thirds of physicians reported having to wait at least one business day for the decision from a health plan on a PA request. Nearly one in four physicians wait an average of three to five days, and 7 percent wait more than five days, the survey found.

This corresponds with the 92 percent of physicians who said PA sometimes, often or always delays patients’ access to necessary care.

“Physicians face additional frustrations when initial PA requests are rejected, with health plans often replying with recommendations for alternatives that make no sense given a patient’s condition,” Dr. Resneck said.

“This leads to resubmissions and additional phone calls to further explain why a patient needs a particular treatment or why the suggested alternative is completely inappropriate,” he added. “The health-plan employees on the other end of these interactions sometimes don’t know anything about the medication I’m requesting, and I find myself explaining diseases and treatments to them all too often.”

Payers agree to work on reform

Some relief appears to be coming. Earlier this year, the AMA joined with other stakeholders—including the insurance industry trade group America’s Health Insurance Plans and the Blue Cross Blue Shield Association—to issue a consensus statement that announced their commitment to improving the prior-authorization process.

More recently, the AMA and Anthem agreed to work together on a number of issues to improve patients’ access to timely, high quality and affordable care. Streamlining or eliminating low-value PA requirements is among the issues the collaboration will focus on.

“I’m so glad that some insurers have recently come to the table to work with physicians on ways to reduce this burden and improve access for patients,” Dr. Resneck said. “We’re working with them to reduce the number of treatments subjected to prior authorization, exempt those physicians who demonstrate high approval rates, improve transparency of requirements, protect patients who are already on treatment, and make submission of PA requests easier.”

Other AMA resources on prior authorization include model legislation and instructional videos on how to reduce administrative burdens by using electronic PA processes that are integrated into a physicians’ electronic health record workflow.

Through the Physicians Grassroots Network and the Patients Action Network, the AMA is giving physicians and patients a way to share their experiences with prior authorization and add their voices to advocacy for reform.

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Comments

I went thru this recently several times with a major insurance carrier. Although I am a physician, my internist and my wife's internist both ordered examinations for pre-auth. The main companies have subbed out the pre-auths to an outside company. They have staffers reading from books and have very little medical knowledge. First both were denied, then naturally they make you go to peer to peer which takes up additional physician time. Finally, since I knew the system, I went directly to customer service ofthe main company, was directly to a company medical director, who authorized the exams in 3 minutes. Almost one week was wasted of everyone's time, going through these inept outside companies. Reminds me of Grisham's book - Rainmaker. Deny, Deny, Deny.
I agree, it’s unbearable. It wastes clinical time and turns us into negative, fighting physicians against the enemy of third party payers. It changes the practice environment to unpleasant. It saves no money as we fight until we get the PA. I’m counting on our major physician organizations like AMA to help abolish preauthorization for usual practice treatments as it is destroying medical practice.
I try to be a thoughtful and careful clinician. I follow my academy’s preferred practice patterns, I go to national meetings, complete all the MOCK requirements, CME requirements, state license renewal requirements .... but most importantly I listen to each individual patient. When I share with a patient that their papilledema or their new onset third nerve palsy could be caused by a CNS process ... they seem to appreciate the need for neuro-imaging. Then we go through a slow, inefficient and redundant process to obtain the PA for an imaging study. My pathology yield on neuro-imaging studies is reasonably high so my profile if analyzed with numerator divided by denominator is reasonably credible. I am sure I am a costly physician in aggregate since I do order tests but I also find disease. What am I supposed to do? See fewer diseased patients?
I remember reading once that ¢72 of every dollar in health insurance premiums goes to administrative and bureaucratic processes rather than providing healthcare. Here's more proof. Insurance companies are their own worst enemy. Imagine the cost of such practices in terms of reduced compliance, delay in treatment and risk of complications. You would think just like the failed gatekeeper and capitation models of the late 80's and 90's that became the badge of shame for HMO's, they would have figured out by now that spending $10 to save 1 is a poor business model. What a waste of time and resources.
Agree with previous comments. We have created a workgroup within Radiation oncology chaired by 2 young Physicians to work with EHR vendors - to see if they could “auto data dump” information required in the prior auth forms. If we could standardize those forms then maybe our clunky EHR can do this automatically. We Physicians or our staff should not be required to (1) call for routine procedure or medications pre-Auth. Our primary care physicians cannot continue to carry this burden. Sheila Rege MD
I would like to see a law that we could bill for these PA's . How can they demand all this physician time and not pay us for it. $25.00 for routine online variety. We could bill an office visit for the long ones needing letters and lots of evidence from patients charts. If it's a 30 minute research effort, bill for 30 minute office visit. All of a sudden we would have far fewer PA's and get paid for the ones we do.
This business of adding webpage javascript PA form completion requirements, probably as requisite to some submission to the webserver, just to write a damn progress note and write a prescription... well... need I say more? You either get that or you don't. Seems many do not. And AMA negotiating is TOO FRIENDLY and NOT in the interests of MD's, who don't need any of that shit, especially trying to explain to some idiot what they've already shown they don't know. But it is never really about that. AMA should be working to ELIMINATE ALL of that, not try to make it work. Does not the AMA know what it is to be in practice trying to help sick people with that kind of gaming going on? The smart young doctors will see this dismay among older peers and wisely choose areas of practice that can be run cash. If you think of Plastics for example, don't let them talk you out of it. Simple general practice cash office. That is how the Oath will survive these big businesses and government games. Perhaps even Big "Union" like AMA games, unless AMA differentiates itself. I am not a damn typist, and I don't fill out javavscript forms to insurance companies for a living. I will go into teaching before I accept that standard for myself.
This business of adding webpage javascript PA form completion requirements, probably as requisite to some submission to the webserver, just to write a damn progress note and write a prescription... well... need I say more? You either get that or you don't. Seems many do not. And AMA negotiating is TOO FRIENDLY and NOT in the interests of MD's, who don't need any of that shit, especially trying to explain to some idiot what they've already shown they don't know. But it is never really about that. AMA should be working to ELIMINATE ALL of that, not try to make it work. Does not the AMA know what it is to be in practice trying to help sick people with that kind of gaming going on? The smart young doctors will see this dismay among older peers and wisely choose areas of practice that can be run cash. If you think of Plastics for example, don't let them talk you out of it. Simple general practice cash office. That is how the Oath will survive these big businesses and government games. Perhaps even Big "Union" like AMA games, unless AMA differentiates itself. I am not a damn typist, and I don't fill out javavscript forms to insurance companies for a living. I will go into teaching before I accept that standard for myself.
When a good doctor examines a patient carefully and writes the indicated prescription according to their best judgment, that is enough. No third party can ever have better judgment, almost by definition, unless they too have examined the patient. No physician should accept any work requirement beyond the good exercise of their knowledge and practice. I always document these refusals and the risk they create and how they have interfered with the treatment plan. Sometimes I find myself documenting dispensation of formulary substitutions, generics, even "similar", other medication than what I prescribed. The note to write is not the one requesting authority to write a damn med - you want to focus on the progress note that documents the treatment plan truncation and delay by the payer. They will have ways to try to make the delay the doctors fault. Always include in the treatment plan the likely denial of prescribed meds, and how you instructed the patient in advance of that possibility, and try to provide a plan B for meds, which can often be wal mart. Better than going the weekend in more pain while the CEO is at the horse races will maybe decide Monday or Tuesday if they wanna follow doctor order or not...
Show Comments (9)
Rebecca Prostko, MD, from the Palm Beach Accountable Care Organization
Jul 20, 2018
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