Health plans often require physicians and providers to obtain prior authorization before a patient receives a specific procedure, device, or prescription. In theory, prior authorizations intend to lower the cost of care and ensure the treatment plan is safe for the patient. Unfortunately, prior authorizations burden administrative staff, which leads to delays and often suboptimal health outcomes.
The consequence of these disruptions has a cost too. The American Medical Association estimates that prior authorizations require 1 physician hour per week, 13.1 nursing hours per week, and 6.3 office hours per week. Although the time input may appear trivial at first glance, physicians and staff do not receive compensation for this workflow, which increases overhead costs for practices.
Medical practices must streamline processes to alleviate the burden of prior authorizations. Here are four solutions for your staff to consider:
A Focus on Process
Outline step-by-step instructions for prior authorizations with each payer. Each payer has a unique process and required forms for their protocol. A written process will help guide your staff through the task from prior authorizations to approvals, denials, and appeals.
We also recommend building a directory that summarizes contact information for each payer. Practices also benefit from documenting which payers require prior authorizations by generating a list of your billable codes and prescribed medications. Customize this list in a spreadsheet format—document whether each of your in-network payers requires prior authorization for the procedure or medication. Your staff can then reference this customized workbook and save hours on the phone speaking to insurance carriers.
Many insurance carriers offer online pre-authorization processes. Technology can help automate prior authorizations. Inquire with each of your in-network payers to learn what they offer. Some electronic health records will integrate formulary lists as well.
Pursue “Gold Card” Status
If your clinicians have developed a strong approval record in ordering tests and medications, specific payers may grant them a “gold card.” Clinicians with “gold card” status are exempt from prior authorization requirements with a distinct payer. Not all insurers offer this designation, but we recommend inquiring if you haven’t already. It never hurts to ask.
We also recommend pre-populating forms to save time. By using pre-populated forms, practices can quickly fill in a patient’s demographics to submit a payer’s prior authorization process.
Do you need help documenting each payer’s prior authorization process? Schedule a demo today to learn how we are helping medical practices streamline prior authorizations.