Prior authorization has become more than an administrative headache for physician practices. For some, it now requires dedicated staff, outside consultants and new internal workflows — while patients wait for insurers to approve care their physicians have already deemed necessary.
In an effort to cut back on this burden, UnitedHealthcare released a list of more than 1,700 procedures it will exempt from prior authorization effective Oct. 1 — but physicians remain skeptical as to how effective the cuts will be.
Three physicians recently joined Becker’s to discuss their experience with prior authorization in their practice and how they would redesign the system to better support their patients and workflows.
Question: How would you quantify the prior auth burden in your practice? Has it ever delayed or derailed treatment plans for patients, and do you have any systems in place to manage prior auth effectively?
Sriniviasa Kothapalli, MD. Cardiologist with ChristusHealth (Irving, Texas): Most physicians order the tests based on their clinical judgment and patient preferences.I don’t see any financial incentives to do anything these days as the reimbursement is drastically lower than in the past.so no need for wasting time on pre-certification. Delayed care is a huge problem, waiting for the clearance and many patients were told to go to ER for these reasons to get immediate treatment. Insurance companies should work with the physicians hand in hand to give the best care for the patients. Physician costs are less than 5% in reality.
Richard Novack Jr., MD. Ultimate Bariatrics (Plano, Texas): The burden prior authorizations place on our small private practice is unmeasurable. We pay three full-time people salaries and full benefits, just to sit on the phone and get prior authorizations from the insurance companies for patients. That is a significant amount of practice overhead. We lose just trying to get permission to do surgery for a patient and it doesn’t even guarantee payment. And, yes, patients have definitely been denied surgery, even though they absolutely needed it, And our hands are tied. Often I end up doing those surgeries for free for the patient, because I know that they actually need it and they can’t afford to pay the cost of surgery. These prior authorizations frequently delay care, do little to save money and, frankly, are completely immoral. A 30% reduction is not even close to what’s needed. They should just be not done at all and allow medical decision-making to be done by the physician and the patient. Currently, insurance companies are actively practicing medicine by denying care. I do not believe this is going to improve anytime soon, unfortunately, for everyone.
Vikas Patel, MD. Executive Vice Chair, Department of Orthopedic Surgery at University of Colorado Anschutz School of Medicine (Aurora): Over the last five years, the prior authorization process has become a huge burden for our practice. We have had to hire additional staff and create additional processes to get procedures approved. We even hired a consulting firm that helped us create a prior authorization procedure coding tool to try to help navigate the process. This is especially onerous for any procedure that might be a newer technology no matter how much of an improvement is over the prior standard of care. This often leads to denied procedures, delaying surgeries until after peer to peer reviews can be obtained. This then makes scheduling that much harder as well. Whether it’s for a standard of care or new procedures, these delays are the hardest on patients. They schedule their lives around surgeries and when procedures are delayed they have to completely upend their plans. Additionally, delayed surgeries means more time off of work, and a greater burden on their families.
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