Addressing the Prior Authorization “Pain Point”

by | Last updated Nov 14, 2023 | Published on Mar 15, 2017 | Insurance Verification and Authorizations

Prior Authorization Pain Point
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The relevance of having efficient insurance authorization services is evident from a recent report in Medpage Today which says that prior authorization is a major “pain point” for most healthcare providers. Based on the recent annual meeting of the Healthcare Information and Management Systems Society (HIMSS), the report cites a senior official of the American Medical Association (AMA) as saying that a recent survey had revealed that its members found prior authorization a time consuming process and one that delays patient care. Our medical billing company had reported that prior authorizations were one of the main concerns that came up for discussion in the annual meeting of the Congress of Delegates (COD), the American Academy of Family Physicians’ (AAFP) policy-making body, held last year.

Insurance authorization companies offer prior authorization services to help physicians deal with the hassle of obtaining approval from an insurance company for specific services before the services are provided. Areas where insurance companies require prior authorizations include, but are not limited to:

  • Imaging procedures such as computerized tomography (CT) scans and magnetic resonance imaging (MRI)
  • Medicines such as brand name medications include those available in a generic form, expensive medications, drugs used for cosmetic reasons, medicine prescribed to treat a non-life threatening medical condition, and drugs not usually covered by the insurance company, but said to be medically necessary by the prescriber. Drugs that are usually covered by the insurance company but are being used at doses higher than normal may also need prior authorization
  • Certain dental services
  • Durable medical equipment (DME) and disposable supplies
  • Experimental or investigational procedures
  • Home health care services and hospice
  • Out-of-network lab services and tests
  • Physical, occupational and speech therapy

An AMA survey at the end of 2016 on the issue of prior authorization found that member practices submitted an average of 37 prior authorization requests each week, and that it took an average of 16 hours of physician and staff time to complete them. The Association reported that, in total, 75% of respondents found prior authorization to be quite burdensome, and over a third said that they had to employ staff to work exclusively on prior authorization. That’s not surprising as even with automation, the process involves a lot to phone calls to the insurance company.

Physicians find that more and more things are subject to prior authorization every year. In addition to being a pain for providers, the process can prove distressing for patients as they have to wait for prior authorization to be completed in order to get treatment. There are many reasons why a prior authorization may not be approved:

  • The request was not submitted in a timely manner – the insurance company/pharmacist have to be given enough time to complete the needed steps.
  • The insurance denied the pre-authorization claim.
  • The physician’s office neglected to contact your insurance company.
  • The claim was submitted with an incorrect billing code.
  • The prior authorization period has expired. For instance, even it a particular drug is approved, the approval may only be valid for a limited time, such as for one year, and sometimes for only a month. After that, the process should be started over again.

Partnering with an insurance verification company to manage the prior authorization process is a feasible option for practices. These professionals can manage and streamline the entire pre-certification process. Their dedicated pre-cert specialists work with physicians’ offices to

  • Ensure that claims for treatments or services that require pre authorization are submitted promptly
  • See that prior authorization requests are submitted to meet all of the payer’s criteria
  • Minimize submission hassles and eliminate duplicate procedures
  • Reduce in-house expenses on prior authorizations

Leading companies can process thousands of prior authorization requests daily for several health plans. Such services help physicians deliver real value in terms of improved patient care, while maximizing their 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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