Faxing (and refaxing) prior authorization requests, and spending hours on hold with payer representatives trying to get answers, wreaks havoc with productivity in most patient access departments. Evidence shows it also hurts patients’ clinical outcomes.

About one-quarter of physicians say the prior authorization process resulted in a serious adverse event for a patient, according to a survey of 1,000 physicians conducted by the American Medical Association (AMA).1

“It is surprising and highly disappointing that two and a half years after a landmark consensus statement signaled insurers were open to reforming the arduous prior authorization process, little progress has been made,” AMA President Susan R. Bailey, MD, says.2

Physicians still face an overwhelming volume of prior authorizations, confusing requirements, and manual processes, the survey revealed. “It is hard to see how prior authorization is saving health plans money,” Bailey says. Other key findings:

  • A total of 16% of physicians surveyed said the process led to a patient winding up hospitalized.
  • Most physicians (74%) said prior authorization delays resulted in some patients abandoning the recommended treatment plan.
  • Most (86%) said the prior authorization burden has only grown worse over the past five years.
  • Phone and fax remain the most commonly used methods for prior authorizations.
  • Most physicians (67%) reported difficulty in finding out whether a prescription or service needs prior authorization.

Patients are going to start advocating for prior authorization reform, Bailey predicts. “More and more people struggle with care delays. We see this in the many heart-wrenching patient stories submitted on the AMA’s ‘Fix Prior Auth’ grassroots website.”

Thanks to the COVID-19 pandemic, patient access staff are dealing with tighter timeframes for authorizations. People put off care for months; today, many want to make up for lost time — and do not want to wait longer just because a health plan will not give an answer on authorization. “We have a lot of patients coming for appointments now, but we have less lead time. We are getting less time to do everything we need to do,” says Michael Sciarabba, CHAM, MPH, director of patient access services at UChicago Medicine.

Payers normally take a week or two to give an answer on authorization. Now, patients want appointments on short notice. “Payers haven’t adjusted to that. They still have their rules in place,” Sciarabba observes.

In response, Sciarabba’s department revamped its insurance verification process. Any appointment less than three days out is considered an “add-on.” A different process is used for those appointments. “If we put them through our normal workflow process, we probably wouldn’t get the auth in time,” Sciarabba explains.

The real problem, according to Sciarabba, is that “the payers aren’t changing their requirements, despite the fact that the whole world has changed.”

If someone makes an appointment for a procedure or test that needs an authorization, staff submit the request that same day. Someone follows up the next day. The department has enjoyed some success in securing quicker authorizations using this method.

“We are submitting the auths on the date of service, or the day before the service, and found a lot of them are being approved,” Sciarabba shares. This saves appointments from cancelation. The downside is that it is a labor-intensive process for patient access. “We are having one or two people focus just on the concurrent auths,” Sciarabba says. Recently, a patient was happy to make a long-awaited appointment five days out. Staff immediately set to work on securing authorization.

However, the day before the appointment, there still was no answer from the health plan. Staff had no choice but to call the patient (who had already taken a day off work for the following day’s appointment) and ask him to reschedule the visit.

Registrars went into high gear, doing everything possible to obtain a payer response. First, staff made multiple phone calls asking for the request to be escalated to a supervisor. Next, staff talked to a care management nurse, asking her to authorize the service. “We basically said, ‘Your patient and our patient has been waiting three months for care. He is unhappy, and it could be unsafe,’” Sciarabba says.

Finally, the nurse authorized the service. Patient access brought the man in for an appointment the following day. “It took a lot of extra work,” Sciarabba says. “But we got it.”

REFERENCES

  1. American Medical Association. 2019 AMA prior authorization physician survey.
  2. American Medical Association. Consensus statement on improving the prior authorization process.