The trusted source for
healthcare information and
Complying with health insurance companies’ prior authorization requirements is demanding ever-increasing resources from patient access. The authors of multiple recent studies found these requirements also stop patients from receiving needed — and sometimes life-saving — medical care.
“Some patients may not have time to waste while waiting for responses from insurance companies,” notes Zachary Wallace, MD, an assistant professor of medicine at Harvard.
As a practicing rheumatologist and clinical researcher, Wallace was in a unique position to understand how prior authorization requirements affected patient outcomes. “I have spent countless hours on the phone doing peer-to-peer discussions and providing literature supporting my treatment decisions,” Wallace recalls.
After seeing prior authorizations become an obstacle to treatment repeatedly, Wallace and colleagues decided to analyze the issue closely. They reviewed the care of 225 patients for whom an infusible medication was ordered between July 2016 and July 2018.1 Of this group, 71% required a preauthorization. For patients who did not require an authorization, the median time to first infusion was 27 days, compared to 31 days if the auth was required. In cases where the auth was denied initially, it took much longer (50 days). Most (79%) authorizations were approved on the first try. Of the 21% that were denied initially, 82% were approved after appeal. Overall, 96% of the infusible medications were approved. “The findings certainly have significance for revenue cycle leaders,” Wallace notes.
There are two important roles for patient access employees, according to Wallace. One, identify alternative payment options if patients cannot wait for the payer to respond. Two, warn patients upfront that prior authorization delays could affect their care. “This sets expectations early on,” Wallace adds.
Many other studies have linked prior authorizations to treatment delays, emotional distress, and worsening symptoms. Some recent findings:
“Medication deviations and delays due to prior authorization requirements are frequent for children with cancer and blood disorders,” says David Dickens, MD, FAAP, clinical director of pediatric oncology services at the University of Iowa Stead Family Children’s Hospital.
Half the oncologists Dickens and colleagues surveyed believed treatment delays negatively affected care. Two-thirds of oncologists surveyed said delayed treatment caused emotional distress for patients or families.5 The findings were not at all surprising, says Dickens — “not to healthcare providers responsible for preventing deviations or delays in the care of pediatric cancer patients, nor to the parents who must wait for the adjudication process to resolve.”
The study findings point to the need to define medically necessary therapy for children with cancer, and agree on terms for prior auth requirements. This kind of payer/provider collaboration, says Dickens, “represents an opportunity to reduce wasteful spending and specious nonpayments.”
A typical scenario: A 2-year-old girl is admitted for urgent, standard chemotherapy for a new diagnosis of leukemia. Two weeks into therapy, her parents receive a letter from their insurer, indicating the treatment will not be covered because a prior authorization was not obtained. “I have now worked at two institutions where there is a standard line item for nonpayment due to prior auth not in place, and considered as an acceptable and ongoing loss,” Dickens shares.
It seems simple to patients: Their doctors order tests, so patients need to undergo those tests. Stress levels soar if payers stand in the way of that happening. “There is an overall feeling of frustration about the process,” says Kaylin Fogarty, director of patient access and financial coordination at Tufts Medical Center in Boston.
Typically, payers take five to 15 business days to give an answer. In reality, neither the hospital nor the payer has enough resources to quickly manage the countless requests for authorization. “Just as staffing impacts our ability to work days out, the same issue can occur with the payers,” Fogarty explains.
Registrars are stuck explaining all of this to patients who just want to undergo a test or procedure. “Payers ultimately control whether they approve or deny a case — and when,” Fogarty notes.
Registrars do their best to manage expectations, since delays are going to happen even if everything on the front end is handled perfectly. “If the payer is reviewing cases only within two days of the expected date of service, it doesn’t matter if we submitted it weeks in advance,” Fogarty says.
For patient access, the main focus is on putting all clinical documentation in place to justify that the service is medically necessary. Even so, says Fogarty, “we are still stuck waiting for the response.” Some frustrated patients end up calling their health plan directly to speed up the process. “This often causes more harm than good,” Fogarty cautions.
Sometimes, payer reps inaccurately claim the hospital just submitted the auth request one day ago. This makes it look like patient access was sitting on it for days without taking action. “The payer doesn’t always explain that the claim is in a peer-to-peer because more clinical information is needed,” Fogarty observes.
Meanwhile, patient access does everything it can to avoid a worst-case scenario. No one wants to call someone the night before a scheduled procedure to tell them it is not going to happen because the payer did not give an answer. “We do everything in our power to make sure if it does happen, it was not because of a delay or error on our side,” Fogarty says.