An AMA survey found that practices reported submitting an average of 37 prior authorization requests each week, with an average of 16 hours of physician and staff time to complete them.
This article first appeared February 22, 2017 on MedPage Today.
The healthcare industry hasn't eliminated the hassles for providers that prior authorization often entails, but they're getting closer, several speakers said here at Healthcare Information and Management Systems Society (HIMSS) annual meeting.
"Studies have shown that prior authorization is the biggest 'pain point' among providers," Pam Jodock, senior director of healthcare business solutions at HIMSS, said at a Tuesday morning meeting session. "The issue is not automation; it's the business processes to which automation would be applied."
The six groups represented at the morning session are hoping to develop consistency in the requirements for getting a prior authorization and reducing the number of treatments and procedures that require it, she added. "The fact that we have six [groups represented] is because this is a critical issue of everybody on the stage today."
Standardizing the Transaction
Bob Bowman, an associate director at CAQH CORE, an organization focused on streamlining healthcare business processes, said that his group has been working on prior authorization for 3 or 4 years. CAQH has developed a rule set to standardize prior authorization transaction, which includes "basic infrastructure requirements, response times, connectivity, and time-stamping," he said.
CAQH CORE also has established a six-member prior authorization advisory group that is trying to find more issues to address in this area, said Bowman; he noted that a 2016 CAQH survey found that the adoption of a standardized form—known as 278—mandated by HIPAA for prior authorizations only had an 18% adoption rate.
"Prior authorization is a huge issue," said Heather McComas, senior policy analyst at the American Medical Association (AMA). "We hear about this issue all the time from our members. Even more than that is the patient impact; they see that care can get delayed by this process and it really upsets them."
The AMA surveyed its members on the issue at the end of 2016 and found that practices reported submitting an average of 37 prior authorization requests each week, with an average of 16 hours of physician and staff time to complete them. "That's two business days—a lot of time," McComas said.
In total, "75% of respondents found prior authorization to be quite burdensome, and over a third reported having staff that work exclusively on prior authorization."
The AMA convened a prior authorization reform work group to discuss the issue; the group released its key principles a month ago. The association is also partnering with the University of Southern California in Los Angeles on a project to look at the costs associated with prior authorization, as well as how it is impacting patients.
"I hear from physicians anecdotally every year that more and more things are subject to prior authorization," she said.
Simplifying the Process
Some insurers have come up with their own solutions to simplify the process. "Our 'pain relief' strategy is to meet providers where they are, so they don't have to undertake a huge IT lift to make these [things] happen," said Elizabeth Hartley-Sommers, clinical data exchange manager at Blue Cross and Blue Shield of Louisiana. "We know where the money on administrative expenses is spent—it's mostly spent on prior authorization" rather than claims payment, eligibility verification, or claims submission. "It's a huge pain point for us and for providers, and for our members, because they're waiting for prior authorization to be completed in order to get treatment."
The increased cost of prior authorization comes mostly from the paperwork and the time expended. "It's a resource-waster and it can be done better," said Hartley-Sommers. "There are a lot of phone calls and secondary phone calls and faxes related to prior authorization."
The plan introduced an online authorization portal which allows providers to enter their own authorization information; they receive instant notification if their procedure is approved. "So far, our providers love it," she said. "They love not having to mail us huge boxes of medical records. They have noted they don't have to do as much faxing or save as much of that paper trail."
The plan also wants to work on more structured data standards; "right now everything is in PDF or TIF format," she said. "We also want to increase adoption of the 278 [form] and make sure we're in line with the industry moving forward."
Another organization working on this issue is the Healthcare Administrative Technology Association (HATA), a group of 33 businesses including practice management software vendors, value-added vendors, clearinghouses, and associations representing vendor clients. The 3-year-old organization held a strategic planning meeting last year and came away with three areas it wanted to work on, including prior authorization. HATA then established a work group on the issue.
"We didn't want to come up with a miracle cure, but we did feel like we could really identify what was the practice management vendors' perspective on the prior authorization transaction," said Sherri Dumford, a program consultant for the group. "We wanted to research and understand the barriers to developing a meaningful workflow for physician use, and how value-based payments might affect prior authorization in the future."
The panel also included Gregg Allen, MD, chief medical officer of eviCore, a vendor that processes 75,000 to 85,000 prior authorization requests daily for more than 100 health plans. "We have been working hard on this over time," he said. "We see the frustration. We spend a lot of time with physician offices talking with them ... day to day."
"A lot of [the issue] is, how do we get the right amount of information that's pertinent to a good care decision? That's not so easy to do," he added.
Currently, about 65% of prior authorization cases are initiated through the company's web portal, he noted. "For about 8 or 9 years, we have been very purposeful at driving people to use the web portal and ... not [have to] talk to anybody," Allen said. "We also have decision algorithms that ... give immediate feedback on whether a [procedure] is likely to be considered appropriate."
But even with all of that automation, prior authorizations still involve a lot of phone calls, Allen continued. "We'd like to see the peer-to-peer calls go away; we're bound and determined to find ways to do that. At the same time, these programs are not going away any time soon, and they do deliver real value in terms of improved patient care and the elimination of duplicate procedures."
Looking Ahead
Charles Stellar, president and CEO of the Workgroup for Electronic Data Interchange (WEDI), a quasi-governmental organization that advises the federal government on the use of health information technology, said his group has been "working to identify the challengers that prior authorization submitters experience ... We are looking for ways to streamline the process to get the decision for prior authorization requests to the submitter in or as close to real time as possible."
He noted that among the groups represented at the meeting session, "It may be that we are replicating in our various activities but I suspect there's a great deal of lessons we could learn from each other. I have talked with colleagues about facilitating a group that would bring us all together, making prior authorization great again."
"There is an opportunity to see this through, to make the patient not wait, and the opportunity to have a better system," he added. "We are excited about this as an opportunity."