Prior Authorization Process: How to Ease the Process For Your Organization

In June 2022, while playing softball, I felt a horrible pain in my hamstring and collapsed like a baby deer learning to walk. The next day, when I couldn’t walk or sit without excruciating pain, I went to an orthopedic urgent care and paid out of pocket for the visit. The doctor examined my injury and suspected a grade three hamstring tear, predicting that it should improve within a few weeks. However, when my hamstring didn’t seem to heal as expected, my primary care physician (PCP) ordered imaging. Unfortunately, my insurance required prior authorization for this service. As a result, it took three weeks after the order was placed before I could get an MRI, which confirmed a complete rupture of my hamstring. This delay in treatment was frustrating, even though I have “good” insurance and have worked in the industry for nearly twenty years. Many people face far worse situations.

Whether you’ve worked in healthcare or have been a patient, you’ve likely experienced the frustration of needing a prior authorization.

The American Medical Association (AMA) survey on prior authorization highlights its significant impact on healthcare providers and patients, including delays in care, adverse patient outcomes, and administrative burdens. Many physicians believe that prior authorizations lead to treatment delays, negatively affecting patient health. The survey also underscores the need for reforms to improve the efficiency of the prior authorization process. For detailed findings, view the full survey here.

According to the AMA Prior Authorization Physician Survey, 94% of respondents reported that the process of obtaining prior authorization delayed access to necessary care, and 78% said that treatment is sometimes or often abandoned due to these delays. Additionally, patients are frequently forced to try alternative treatments, even when these are known to be ineffective. On average, organizations complete 43 prior authorizations per physician per week, totaling up to 12 hours. To make matters worse, 27% of physicians report that prior authorizations are often or always denied, a significant increase over the past five years. Furthermore, 61% of physicians participate in “peer-to-peer” reviews, adding to the overall burden, cost, and frustration.

So what can be done? While prior authorizations are unlikely to disappear soon, there are steps you can take to ease the process for your organization:

1. 🗂️Streamline Documentation:

   • Implement a standardized workflow for submitting and tracking authorizations. Many organizations divide the authorization process between clinical and revenue cycle staff. Having a clearly defined workflow with outlined roles and responsibilities helps prevent things from falling through the cracks. In athenaNet, you can utilize the integration between clinical orders and the creation of authorization placeholders in the patient’s Quickview.

2. 🗓️Advance Planning:

   • Identify common procedures and medications that frequently require authorization and prepare the necessary information in advance. Ensure all staff are aware of these requirements. If there are delays in obtaining authorization, have staff contact patients to reschedule appointments. Reviewing denial patterns and implementing preventive measures can help ensure timely authorization. Your athena CSM can help identify payers and services with high denial rates and set up custom rules for services that require authorization. Even with advanced planning, last-minute additions are common in healthcare. Implement reporting to verify that all authorizations have been obtained and to address any last-minute procedures needing STAT authorizations. Set up automatic reports delivered to the appropriate staff members.

3. 💻Utilize Your EHR:

   • Athenahealth’s EHR system integrates the authorization process, reducing the need for manual paperwork and minimizing the chance of errors or lost information. It also enhances communication among staff coordinating procedures. Rather than relying on physical notes and orders, take advantage of the clinical inbox for better transparency and organization.

4. 🗣️Advocate for Policy Changes:

   • Work with professional organizations to advocate for policy reforms that reduce unnecessary prior authorization requirements. While the government has yet to lead significant reform, industry efforts such as the 2018 Consensus Statement on Improving the Prior Authorization Process have been made. However, despite these efforts, many physicians feel that the burden has increased rather than decreased.

At Ignite, we are dedicated to helping our customers standardize and streamline their authorization processes. Our experts can evaluate your current workflow and provide recommendations for optimization. With expertise in both clinical and revenue cycle management, we offer comprehensive support. If you have any questions or need assistance, please reach out to speak with one of our staff members. Contact us today!

-Amanda Van Cleave, Director of Consulting

Reference: AMA Prior Authorization Survey