Prior Authorizations: Present Issues and Solutions

Prior authorization (PA) is required by health insurance companies as a condition of payment for numerous services. Payers utilise PA to decide whether or not particular medications, products, treatments, or services are medically required before prescribing or providing them to beneficiaries. However, the PA process imposes an administrative burden on physicians' offices and managed care organisations, and often has a negative impact on patients by delaying required therapy.

According to a recent health leaders report, such support is especially important now because payers are requiring prior permission for patient care even while the COVID-19 pandemic persists. Though some payers eased their PA requirements in response to the COVID-19 pandemic, many of them reinstated them as the pandemic progressed.

Prevailing Prior Authorization Issues Revealed

According to a new AMA poll, 94% of physicians indicated that PA requests caused care delays, and 79% claimed patients abandoned treatment due to authorization complications with insurance. The poll, which was performed in December 2020, included 1000 practising physicians. The following are the report's other significant findings:

• PA programmes, according to 90% of physicians, have a detrimental impact on patient clinical outcomes.
• 30% of respondents said that PA requirements resulted in major adverse events for patients under their care.
• The burdens associated with PA were rated as severe or extremely high by 85% of respondents.
• Only 15% of physicians said PA criteria were frequently or always based on evidence-based medicine.

Recommendations of the ACR on Prior Authorizations

The American College of Rheumatology (ACR) issued many proposals in March 2020 to lower PA requirements and increase patient access. Among the suggestions were:

Reducing the number of clinicians who are subject to PA requirements if they use evidence-based practises and achieve performance metrics and other standards.

Reducing the number of treatments and drugs that require PA by assessing and deleting extraneous requirements on a regular basis.

Improving transparency and communication channels among payers, patients, and physicians

maintaining continuity of treatment when coverage, payers, or PA requirements change, and

accelerating the adoption of national electronic PA standards and increasing transparency about formulary decisions and coverage limitations

In January 2021, the Centers for Medicare and Medicaid Services (CMS) issued a new regulation to streamline the PA process and improve data transparency for providers, payers, and patients.

Certain payers, providers, and patients will have electronic access to pending and active prior authorization (PA) decisions under the regulation. The new rule, according to CMS, will:

• Allow providers more time to focus on providing higher-quality care.
• encourage interoperability by promoting secure electronic data access
• empowering individuals, lowering expenses, and easing the stress on the health-care system

The new rule requires authorised payers to establish application programming interfaces (APIs), which will allow providers to access data via integration with their electronic health records. This information will include claims and encounter information, as well as laboratory results and information on any pending or active PA judgments.

APIs will ensure that healthcare providers have more complete information about their care, which is expected to improve the patient experience. APIs will also make it easier for patients to access their health information.

CMS indicated in a statement issued the first week of April that, in recognition of the difficulty faced by payers during the COVID-19 public health emergency, the agency will not implement the new policies and technology standards for interoperability and burden reduction until July 1, 2021.

According to the American Medical Association's 2020 report, the prior permission burden has a major impact on medical practises. Practices complete 40 prior authorizations per physician each week on average, which requires two business days (16 hours) of physician and staff labour.

According to the AMA, these findings highlight the need to streamline or abolish low-value prior-authorization restrictions in order to reduce delays or disruptions in care delivery.

"Delayed and disturbed treatment can have life-or-death repercussions for patients, especially during a public health emergency," stated AMA President Susan R. Bailey, MD. "This painfully acquired lesson from the current crisis must inspire a reexamination of administrative costs imposed by health insurers, which are frequently unjustified," she said.

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How Prior Authorization Outsourcing Can Help

Insurance authorization services can help patients and clinicians deal with the stress of prior authorization. A team of insurance verification specialists from an insurance authorisation business will work with practises to:

• Ensure that claims for PA-eligible treatments or services are submitted on time.
• Before submitting a PA request, ensure that it meets all of the payer's requirements.
• Reduce submission hassles and reduce redundant procedures.

These businesses have a streamlined, centralised approach in place that reduces errors. They have also worked with all government and private insurers. Working with an expert allows practises to save time and resources required for prior authorizations services while also lowering the likelihood of denials, which benefits both physicians and patients.