3 Ways to Outsmart Prior Authorization Ploys

Posted on 15 Sep, 2017 |comments_icon 0|By Elizabeth

Payers get the upper hand because they are huge companies that can funnel resources into figuring out how not to reimburse you. Their most recent shell game is prior authorization.

“When I started out [prior authorization] never came up,” says Kevin de Regnier, an osteopath who has practiced for more than 25 years. “Then we started seeing it in a small number of high-dollar medications, then it expanded into more and more branded medications, and then moved into getting procedural prior authorizations, especially in the radiology field. Now you’ve got to prior auth for every procedure and every referral, even referrals for physical therapy.”

It may feel like you’re the only physician or practice manager who spends the bulk of your day on the phone justifying procedures and medications, but you’re not alone. In 2016, the American Medical Association conducted a survey of member physicians to assess their prior authorization experience.

The results were striking: 75 percent of respondents called their administrative burden “high.” No wonder, when they averaged 37 prior authorization requests per week with an estimated 16 hours spent weekly on those requests. As a result, one-third of the physicians hired a staff member whose only job was handling prior authorizations.

“Because of the number of things that authorizations are being required for, I know an eight-doctor group that has a staff member who spends 80 percent of their time just doing prior authorizations for tests,” says Jill Young of Young Medical Consulting.

Win the Prior Authorization Game

Despite the pain of prior authorization, your practice can take concrete steps to make the process more efficient.

  1. Put the right person in charge. “Don’t have your least experienced person handle prior authorization,” warns Young. “They have to be savvy.” It isn’t a task for your newest employee, even if it might seem like mindless work at times. An experienced hand can drastically speed up prior authorizations.
  2. Embrace newer technology. Many prior authorizations are still done by telephone or fax, even as more and more business is conducted online-only. Whenever possible, says California-based medical consultant Judy Bee, use the payer’s website for all prior authorization requests.

This step eliminates the dreaded wait time on hold that is the bane of every medical practice. Even if using the online option only slightly reduces the time needed to hear back from an insurer, it saves hours of dead time on the telephone.

  1. You may be able to work out special pre-approval deals with insurers to circumvent the prior authorization process. “Tell the payer that if the patient presents with this disease, this is what we will do,” Dahl recommends. Then ask, “can we get blanket approval for this without having to call every time for authorization if the patient needs a procedure under this treatment plan?

Creating condition-specific plans of care in advance lets you focus on what you do best: treating your patients, not waiting for the go-ahead from a far-off insurer.

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Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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