Prior Authorization

Pains of prior authorization create pressure for reform

Troy Parks , News Writer

The burdens of prior authorization (PA) are becoming a high-priority item for physicians and payers alike, according to several organizations gathered at the Healthcare Information and Management Systems Society’s (HIMSS) annual conference in Orlando, Florida, to share pain points from both sides of the PA equation. Discussion at the well attended breakfast panel appeared to reflect a new interest in improving the PA process for patients, clinicians and payers.

One payer representative explained how PA woes are being addressed in Louisiana.

Prior authorization “is a huge pain point for us and our providers,” said Liz Hartley-Sommers, a registered nurse and clinical data exchange manager at Blue Cross Blue Shield Louisiana (BCBSLA). The issue also affects patients, she said. “Because those people are having to wait for prior authorizations to be completed in order to get treatment.”

BCBSLA recently took a look at ways they could improve prior authorization and decided they wanted to give physicians options so they “don’t have to make a huge IT lift to make it happen,” Hartley-Sommers said. “We also wanted to automate as much as possible” and decrease the noise and duplicate efforts, such as extra phone calls and faxes on the same PA request.

After uncovering those pain points with their physicians and patients, BCBSLA took a new approach that allows physicians multiple options for completing PA requests. Physicians can electronically submit PA information in the plan’s web portal and receive an immediate notification as to whether the request was approved. BCBSLA also supports the standard electronic PA transaction, or the X12 278, and offers secure, automated electronic medical records requests in several locations.

“So far, our providers [have] loved having the option, being able to choose—not being forced to abide by whatever standard or whatever software we put out.”

“They love not having to mail us huge boxes of medical records,” Hartley-Sommers said. “They also have noted that they don’t have to do as much faxing or maintain as much of that paper trail because everything is done through automated electronic notification.”

The AMA in December conducted a Web-based survey of 1,000 physicians to investigate the toll PA is taking on physicians and their patients. One of the more alarming findings is that practices reported completing an average of 37 prior-authorization requests per physician per week, taking up over 16 hours of physician and staff time.

“Sixteen hours … that is two business days,” said Heather McComas, a pharmacist and director of administrative simplification initiatives at the AMA. “So it’s not too surprising to hear that physicians find prior-authorization burdens to be ‘high’ or ‘extremely high’—75 percent.”

“Over a third of our surveyed physicians reported having staff that work exclusively on prior authorization,” she said. “I think we can all agree that there are a lot better ways for people to spend their time.”

Based on the burdens revealed by the survey, the AMA and a coalition of 16 other organizations representing physicians, hospitals, medical groups, pharmacists and patients came together to discuss their biggest concerns with PA and cultivate best practices to reform this process.

The result of the effort is a set of 21 principles to dramatically reshape PA requirements to ensure they are clinically valid and implemented in a way that is transparent, timely, efficient, flexible and standardized. The coalition calls on utilization management programs such as PA to have a clinically accurate foundation for physician adherence to be feasible, among other reform objectives.

“We want to reform prior authorization,” McComas said. “We want to reduce the burdens and make sure patients are getting their care in a timely way.”

“The reason that physicians get so upset about this issue is the patient impact,” she added. “They see that care can get delayed by this process and it really upsets them because they care about their patients.”

The Workgroup for Electronic Data Interchange (WEDI), an organization designed to bring together key organizations from across the health care spectrum to improve health care information exchange, has established a prior-authorization workgroup “to identify the challenges that electronic prior authorization submitters experience that keep or deter them from submitting the prior-authorization requests electronically,” said Charles W. Stellar, CEO of WEDI.

The overall goal, Stellar said, is to “streamline the process to get the decision for prior authorization request to the submitter in as close to real-time as possible.”

There are many groups and organizations now working to improve the prior-authorization process, Stellar said. But it’s important to note where those efforts overlap and where everyone can work together.

“I suspect that there are a great deal of lessons that we can learn from each other,” he said. “There is an opportunity to see this through into a process that will make the patient not suffer, not wait, and … to have a better system.”