In their line of work, physicians carry tremendous responsibility and heavy workloads. Working late. Being on call for 24 hours straight. Visiting patient after patient without time for a break.
In this modern age of medicine that embraces the concept of value-based care, additional administrative tasks are mounting for physicians. One of those is prior authorization (PA) or pre-certification. Join us as we look at the administrative burden of PA, how this process can hinder a patient’s access to medication, and how prior authorization software can help.
What is Prior Authorization?
As defined by the Academy of Managed Care Pharmacy in a PDF report, “Prior authorization (PA) is an essential tool that is used to ensure that drug benefits are administered as designed and that plan members receive the medication therapy that is safe, effective for their condition and provides the greatest value. Prior authorization requires the prescriber to receive pre-approval for prescribing a particular drug in order for that medication to qualify for coverage under the terms of the pharmacy benefits plan.”
Specifics apply to each state and insurance company, but prior authorization is typically applicable for cost reasons or because they prefer another type of medication or treatment.
Providers are Becoming Increasingly Burden with Prior Authorization
Physician practices are finding themselves consumed with the task of prior authorization. How consumed? On average, practices spend two business days per week to comply with the inefficient and overused protocols for prior-authorization used by health plans. According to a 27-question web-based survey completed by 1,000 U.S. physicians that provide a minimum of 20 hours of patient care per week by the American Medical Association (AMA), prior authorization has become increasingly burdensome. Interesting facts showed up in the study including:
- Ninety percent reported the administrative burden of PA requests has risen in the last five years with the majority reporting a “significant” increase.
- Up to a third of all practices now employ staffers that work exclusively on requests and follow-ups for prior authorization.
- Medical practices complete an average of 29.1 PA requests weekly which consumes 14.6 hours just in the processing of these requests.
- Half of those requests were for prescriptions and the other half were for medical services.
- Ninety-two percent of those physicians surveyed reported that the prior authorization requests cause delays in care.
In a press release from the AMA, Jack Resneck Jr., MD, a health policy expert and professor of dermatology at the University of California, San Francisco, felt the results of the survey demonstrate how this reality holds back physicians from performing even the most basic primary tasks, such as ordering routine prescriptions. He stated:
“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 treatment. This survey demonstrates the increasing burden. 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. 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.”
Does Prior Authorization Prevent Patients from Receiving the Care they Need?
Red tape imposed by insurance companies is causing potentially deadly barriers to those seeking treatment for opioid addiction according to an article in the Health News Review. Buprenorphine is a medication which helps reduce cravings and prevents feelings of withdrawal in order to help people break out of the deadly cycle of addiction. By taking this medication therapy, patients are at less risk for behaviors associated with obtaining opioids on the streets and it helps them to maintain a normal daily life. Furthermore, the risk of death from overdose is dramatically decreased with the use of this medicated-assisted treatment (MAT).
With all the benefits of this MAT, why are patients facing issues with insurance companies for prior authorization?
Sarah Wakeman, MD, a specialist at Massachusetts General Hospital, explains that if PA is not obtained, then a doctor can write a prescription but the pharmacy would be unable to fill it. The provider must first fill out a form providing more information and submit this to an insurance company and wait for a reply which can take 72 hours. According to Wakeman:
“In the setting of opioid use disorder this can mean 72 hours where a person is at imminent risk of death from overdose”
An opinion piece written by a doctor in the Washington Post attests to the dire impact prior authorization can have on patients that need access to life-saving medication. The article explains how medications that assist with addiction therapy are shown to at least double the chances of a patient remaining clean from illicit opioids and greatly decrease the incidence of death from an overdose. Of all patients that try to quit heroin use without help from MAT, approximately 80 percent relapse within the first month after detox.
It’s hard to know what to expect, but invariably one type of message awaits: voice mails from pharmacies informing me that a patient’s insurance provider will not approve payment for the medication to treat their opioid addiction unless I obtain prior authorization from the insurer. Buprenorphine-naloxone, commonly known by the brand name Suboxone, and other medications, such as methadone and naltrexone, are used in combination with therapy and mutual-help groups to offer a new life for patients with opioid addiction. – Brian Barnett, Washington Post contributor
Prior Authorization Software Eases the Administrative Burden on Providers and Provides Convenience for Patients
At the SSI Group, we provide robust prior authorization software that helps ease the administrative task of completing PA requests for physicians’ practices and hospitals. Furthermore, patients benefit from being able to access the care they need as quickly as possible.
Who can begin the process of electronic prior authorization? Patient access staff, also known as registrars, are the primary parties responsible for the submission of prior authorization or pre-certification requests in the hospital setting. In the physician practice office setting, other employees, such as secretaries and even physicians, are the ones who can behind the process of electronic prior authorization. The electronic submission of pre-certification data helps to streamline workflow and eliminate the need for the cumbersome manual processes that were once relied on.
The SSI Group technology provides a feature known as intelligent guidance, which prompts staff members to request the right and complete information from the patient at the right time to ensure all patient payor information is submitted accurately in order to improve the hospital revenue cycle. Learn more about our solution for prior authorization software that is a component of our patient access solutions here.