Healthcare providers and physicians are plagued by a complex myriad of utilization management rules, in particular the prior authorization requirements, when insurers are seeking pre-approval for procedures. The American Academy of Family Physicians (AAFP) explains this common burden faced by healthcare providers managed by health insurance companies in their recent interview-article.

One family physician, Jennifer Aloff, M.D., who has been taking care of patients since 2001 in a five-physician practice in Midland, Mich., explains how practicing medicine has become more tedious due to the increasing regulations. She says:

“Dealing with the prior authorization process is the most frustrating aspect of my medical practice overall and has become increasingly time-consuming and complex. In my office we now have a full-time staff person to deal with prior authorizations and referrals.”

Coalition Proposes Reform to Prior Authorization

In January of this year, 17 healthcare organizations, including the American Medical Association (AMA) and the Medical Group Management Association (MGMA) have joined forces to attempt to ease the burden of adherence to prior authorization requirements as they apply to healthcare providers. This coalition effort is aimed at asking benefits managers, health plans, and healthcare stakeholders to reduce the administrative burden of getting prior authorization approval, as reported by Healthcare Finance News. As stated by the AMA:

“Concerns that aggressive prior authorization programs place cost savings ahead of optimal care have led Delaware, Ohio and Virginia to recently join other states in passing strong patient protection legislation.”

Modern Healthcare reported that the coalition announced earlier this year that they will lobby health plans to “streamline prior authorization for medical tests, procedures, devices and drugs,” because according to them, the current process is overly time-consuming and has a negative impact on patient care.

21 Principles Drafted by the Coalition for Reform

Together, these organizations have drafted 21 principles for the use prior authorization requirements in health plans. Rob Tennant, the health information technology policy director at the Medical Group Management Association, explains that the goal of the coalition is to work with individual private insurers and America’s health insurance plans to make these needed reforms. Tennant stated that:

“Our hope is to build a dialogue between providers, health plans and their third parties so we can cut out needless administrative waste from the system.”

As reported by Revenue Cycle Intelligence, Andrew W. Gurman, MD, President of the American Medical Association (AMA), explains that, “Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited healthcare resources and antagonized patients and physicians alike.” He continues by explaining the goals, “The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs.”

The coalition highlights the specific burdens faced by providers that detract from patient-centered care. In fact, according to the article in Revenue Cycle Intelligence, an AMA survey uncovered the following authorization challenges:

  • Medical practices send an average of 37 prior authorizations per physician a week, totaling 16 hours of staff time
  • 75 percent of physicians surveyed cited authorization burdens as either high or extremely high
  • Over one-third indicated that their practice has to employ an individual exclusively for prior authorizations
  • 60 percent of doctors state that prior authorization decisions take at least one business day
  • 25 percent of physicians said that prior authorization decisions take three or more business days
  • Nearly 90 percent of physicians said that prior authorizations often, sometimes, or always delay access to care

Automate the Authorization Process with Technology

The process of manually submitting authorizations and pre-certifications can produce delays and increase an organization’s chance or error. The SSI Authorization and Pre-Certification application can help by automating the process by initiating real-time authorization/pre-certification (278) request at the earliest point in the registration process.

Request a demo today to see how this software can increase improve your cash flow, help reduce claims rejections and improve your overall revenue cycle.