Beating the Prior Authorization Blues -- FPM

The Federal budget is impacted by rising health care costs. There are several factors in play.

1.  Due to increased length of life and successes in treating acute and chronic illness our population is aging. The percentage of patients over the age of 65 increases annually due to bursts of immigration, and birth rates as well as innovations of care resulting in lower mortality rates.

2. There are and will be fewer workers paying into Social Security and Medicare, as well as the effects of automation requiring fewer workers.

Medicare (CMS) attempt to control expenses by limiting procedures.  Private insurance does the same via a complex time-consuming process known as prior authorization.

The enclosed video illustrates the process, time-consuming, as well as non-productive work required by clinicians.

Like many family physicians, W. Ryan Neuhofel, DO, has spent his share of time on the phone asking insurers for prior authorization of medications or medical procedures for his patients.

Unlike many physicians, Neuhofel decided to videotape it. The Lawrence, Kan.-based physician recorded a 21-minute call of himself seeking approval for computerized tomography (CT) scan for a patient with a palpable mass on his skull and then posted the video on several social media platforms, where it attracted thousands of views.

Of course, the tactic has real costs for physicians and their practices. One study estimated that primary care physicians spend an average of 3.5 hours a week dealing with insurers, and the entire medical community spends the equivalent of between $23 billion and $31 billion annually in time on insurance matters, including prior authorization.1

Prior authorization can also negatively affect the quality of care. According to an American Medical Association survey, two-thirds of physicians said they waited at least a few days for preauthorization on tests, procedures, or medications, and between 10 percent and 13 percent said they waited for more than a week.  Insurers and other payers have long used prior authorization as a valuable tool. Lydia Bartholomew, MD, of Edmonds, Wash., is a medical director for a national insurer and a member of the American Academy of Family Physician's (AAFP's) Commission on Quality and Practice. She said insurers require prior authorization to confirm that the treatment prescribed by the physician is covered by the patient's health plan and is the most appropriate care in the best setting. This helps insurers control health care costs by reducing duplication, waste, and unnecessary treatments, as well as identifying patients who might benefit from case management services, she said.

Whether insurers are increasingly requiring prior authorization is difficult to assess. Anthony Akosa, MD, MBA, chief medical officer of HealthEC, which advises accountable care organizations and other large provider groups, believes insurers are reining in their prior authorization requirements to some degree. They are responding to customer frustration over delays or denials of medical treatment, he said. However, growth in high-deductible health plans, which tend to have more coverage limitations, might be contributing to a perception that prior authorization requirements are increasing when in fact more services are being denied for lack of coverage, he said.










Beating the Prior Authorization Blues -- FPM: Getting insurer approval for treatment can take hours out of your week. Here are some ways to reduce the pain.