A winning approach to preauthorization begins with providers and payers “dancing in sync,” said Kenneth T. Hertz, FACMPE, Medical Practice Consultant, Medical Group Management Association, Alexandria, LA, at the 2015 American Urological Association (AUA) annual meeting.
Working with Payers
According to Mr Hertz, regardless of how providers feel about preauthorization processes, payers are still the payers, and “we kind of have to work with them and dance in step with them.” The payoff comes from the fact that “if we’re really good at what we do, we can really improve our chances of being successful.”
Preauthorization is frustrating for practice managers, physicians, and patients, “but if we look to this kind of approach, where we really work together with payers, I think you’re likely going to have a far better result,” said Mr Hertz.
From the provider’s perspective, a winning preauthorization strategy requires consistency, including dedicated personnel and oversight. These qualities are particularly important for practices that have more than 1 location. Centralized oversight and management are key to maintaining consistency and performance from one location to another.
“If you have 6 offices and you have 6 different people doing prior authorization, trust me, it’s being done 6 different ways with 6 different levels of efficiency and effectiveness,” said Mr Hertz. “In many instances, it’s not being done well, because no one is managing it or providing oversight.”
He added, “you’ve got stuff falling through the cracks, and this is one of those things that can’t fall through the cracks.”
The need for consistency and oversight of preauthorization is just as great as it is for payment denials.
“Insurance companies believe we will not effectively deal with denial and come and get them,” said Mr Hertz. “They believe that most of us will let [denials] drop through the cracks, won’t get followed up on, and they’ll never have to pay. It’s the same thing with prior authorization.”
Several years ago, the American Medical Association surveyed its membership about prior authorization and found strong, mostly negative feelings. Almost 80% of respondents favored eliminating prior authorization altogether.
Approximately 66% of the respondents said that payers had vague preauthorization requirements that were difficult to understand. A similar proportion of respondents said that wait times for decisions ranged from several days to weeks. Almost half (43%) of the respondents complained that prior authorization review was performed by people with no medical training.
Improving the situation begins with knowing the patients, the work and services provided, and the payers.
“You’ve got to do the research, you’ve got to catalog it, you’ve got to document it, you’ve got to know what the plan wants, what they request preauthorization for, and what the requirements are for the preauthorization,” said Mr Hertz. “It’s critical. It’s not brain surgery, but it’s critical.”
Managing the Process
“Help your staff prioritize,” he added. “Somebody’s got to manage this. This is so important that you cannot give this to a $10-an-hour employee and expect them to make all of the right decisions, all of the right judgment calls, and handle this properly. It’s got to be managed. It’s that important.”
Practices should leverage technology to develop an efficient and effective process for preauthorization, including Internet portals and the technology that is available or becoming available through electronic medical records (EMRs). The more work that can be addressed by the EMR, the more time that can be cut from handling preauthorization requests, said Mr Hertz.
Pay attention to the wording of prior authorization requests that sail through the process with relatively little delay. Knowing key words and phrases that resonate with payers can help guide the development of requests and improve the efficiency and speed of their processing.
Mr Hertz advised using convincing patient cases to support a request for preauthorization and determining what types of results the payers find convincing and what does not impress them.
“Work with them,” he said. “They are not the enemy.”
He also recommended regularly reviewing the plans that are accepted by the practice. Some plans may have preauthorization processes that have “hassle factors” that are so onerous and reimbursements that are so low that the practice may not want to accept them.
In summarizing his presentation, Mr Hertz pointed to 3 best practices that can improve the preauthorization process, including:
- Using screening services and identifying those that regularly have preauthorization requirements. Preauthorization software, Current Procedural Terminology coding software, and the examination of a payer’s eligibility requirements can facilitate the process
- Automating the practice’s process for requesting preauthorization
- Paying close attention to data accuracy and verification.
Following these best practices can lead to the formulation of a gold standard approach for preauthorization. Practices should prospectively identify the drugs that require prior authorization before sending a prescription to a pharmacy.
Unnecessary forms should be eliminated by sending specific prior authorization questions to the EMR, as determined by the patient, the health plan, and medication. Improvements in the efficiency and the accuracy of the administrative tasks can be achieved by prepopulating the electronic forms with the required patient information.
Ensuring support for real-time communication with pharmacy benefit managers and automatically routing the preapproved electronic prescriptions to the pharmacy can avoid a prior authorization block and delay in processing.
The ultimate goal should be an EMR-based preauthorization that leverages available and evolving technology to achieve maximum efficiency and effectiveness.
“To me, a winning preauthorization process consists of 3 things,” said Mr Hertz. “You must have foresight. You have to think about and plan for prior authorization. You need to develop a process, procedures, and structure.”
He added that, “there has to be coordination. Everybody has to work together. If anyone in your practice doesn’t understand this, then it won’t work.”
“Finally, you need to know what plan requires what. You know a lot of this information, but many times, no one has put it all together,” Mr Hertz concluded.