AAFP’s 2016 Congress of Delegates highlights Prior Authorization Concerns

by | Last updated May 12, 2023 | Published on Oct 12, 2016 | Insurance Verification and Authorizations

Prior Authorization
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The annual meeting of the Congress of Delegates (COD), the American Academy of Family Physicians’ (AAFP) policy-making body, was held Sept. 19-21 in Orlando. The Reference Committee on Practice Enhancement discussed 17 resolutions. Family physicians aired various topics that posed barriers to proper patient care. According to an AAFP press release, prior authorizations were one of the main concerns that came up for discussion. Besides insurance verification, the Reference Committee on Practice Enhancement adopted resolutions relating to a issues such as Medicare’s annual wellness visit, telehealth, and independent practice.

That primary care physicians dread prior authorization is no secret. Insurance companies require preauthorization for certain health care services, treatment plans, prescription drugs or durable medical equipment (DME) before patients receive them. This process of preauthorizing medical care with third-party payers is time consuming and extremely frustrating for primary care practices. Physicians and their staff have to spend time persuading the insurance company to cover a medication or procedure. This can prove an expensive and bothersome distraction from the task of patient care. For instance, the DME prior authorization process can take as long as 10 days. Such delays prevent timely delivery of care, often leading to medical crises and higher readmission rates.

At the recent AAFP’s annual Congress of Delegates, many physicians talked about their personal experiences with prior authorizations. In one case, a patient in the hospital with Pseudomonas pneumonia was sent home and then denied the drug he needed because it was the expensive drug at the time. The patient was later readmitted for another costly hospital stay.

Physicians also spoke about the financial impact prior authorizations have on their practice. One resolution asked the AAFP to encourage the development of a specific time-based CPT code to compensate them for the time they spent on the prior authorization process. Another resolution asked the Academy to support for a per-member, per-month (PMPM) fee from payers to help compensate physician practices for insurance authorization services. Provided by professional insurance authorization companies, these services help physicians avoid problems such as delayed payments, the need for claim rework and resubmission, errors, and nonpayment. With the right service provider, physicians can devote their time to care and ensure timely and proper reimbursement.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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