In this white paper, Randall Davis, Senior Director of Client Operations, analyzes the significant impact of prior authorizations on patient care, emphasizing the delays and complications they cause in the healthcare delivery process.
Click on the video to the right to learn more about the author, hear his insights on this white paper, and learn what motivated him to write about this subject.
To discuss this topic, please contact Randall using the information provided at the bottom of the white paper.
In care delivery, 94% of physicians say prior authorizations (PAs) result in delays. Patients go untreated for longer because of an opaque, complicated approval process. Or they just abandon care as being too hard.1
Not intending to create barriers, 98% of health plans use peer-reviewed, evidence-based studies when designing their prior authorization programs. They expect to improve quality and promote well-grounded criteria. 2
But 74% of physicians score payers’ PA criteria as only sometimes, rarely, or never evidence-based.1 A recent 14M-claim study justified their assessment. 25% of Medicare Advantage services, by net reimbursement, required a PA but would not if billed under CMS guidelines.3 Most payers extend these Medicare Advantage rules to their commercial plans, so we have an endemic problem.
Payer rules, in addition to clinical evidence, must then steer physician decisions. Hidden payer logic undermines physician expertise and costs them valuable time. 85% of physicians count their 40 prior authorizations per week as a high or extremely high burden.1 Frustrated by insufficient time to document their decision details, this increases physician burnout prevalence by 5.8X.4
For physicians, the criteria used for PAs are unclear. They rarely know at the point-of-care if the prescribed treatment requires prior authorization. They only find out later when a patient’s access is delayed or denied.5
PAs form a bitter barrier to patient care that:
A group of leading providers and payers with remarkably diverging interests have expressed consensus for dramatic PA change, including “communication and collaboration.”6 But prospects for transformation are poor.
At Vee Healthtek, we transform the PA process one patient, one physician, and one healthcare system at a time. Our framework assesses historical data, processes, system interfaces, training and automation using the Sona ProMISe platform to completely transform the PA process.
With an integrated Prior Authorization Program we work backward from denied claims, which for one new client reached 22% of revenue. Using Sona ProMISe Analytics, we sift through claims history to assemble clusters of denied accounts into a Pareto diagram of chronic root causes. With workflow maps, decision dependencies, and training scenarios we assemble intelligence on critical gaps into an efficient program for high approval rates.
Invariably, our solution starts at the front of the revenue cycle. We drive quality forward in the process. For a patient’s diagnosis requiring a procedure or medication, plan eligibility research may trigger a PA.
That’s when the hard work starts. Success rests on researching and gaining a thorough understanding of the current rules from the payer plan for this member. Without clear criteria, a PA request is destined for denial.
When a physician orders a procedure, test, or medication, we traverse payer-imposed process steps. Centralizing the entire process using Sona ProMISe Workflow, we inventory clinical requirements and payer rules to map the scenario for approval.
On the payer’s website or the phone, we assess the member’s plan for relevant criteria and overlay the physician’s orders onto those rules. Working from the medical record, we match documentation with payer requirements. With a clean match, we fill the forms from patient EHR records and submit the compliant request.
When documentation is insufficient, we record the criteria and gaps for physician staff in the EHR. With a clear line of sight, the physician can determine whether and how documentation of their findings can comply with the requirements. With light physician involvement, we submit a compliant package.
Through the EHR, website, phone, email, fax, and API we monitor the payer for approval or rejection. We follow up in real time when care is in the balance. If denied, we assess the gap and go back to the physician’s staff for data to resubmit. If the gap can’t be filled but the physician disputes the criteria, we facilitate a peer review. Vee Healthtek drives for the highest PA success rate with the least provider impact. Our goal is to gain authorization up front for all requests. But it’s not unusual for denials to arise at claim submission. We work both the easy cases and the hard ones.
If all this sounds breathtakingly tedious, and it is. Not to worry. With historical experience of provider documentation gaps and payer behavior, we apply Sona ProMISe Automation to the high-volume, repetitive parts. Automation drives down the healthcare system’s cost to collect and further eliminates errors from manual transactions while delivering the transformed PA success rate.
With Sona ProMISe and the discipline of our Prior Authorization Program, our clients reverse the trend, delivering effective care with:
Vee Healthtek enables physicians to focus on delivering patient care without barriers.
1. 2020 AMA Prior Authorization PA Physician Survey. American Medical Association. https://www.ama-assn.org/system/files/2021-04/prior-authorization-survey.pdf
2. AHIP. 2019. Key Results of Industry Survey on Prior Authorization. https://www.ahip.org/wp-content/uploads/Prior-Authorization-Survey-Results.pdf
3. Schwartz, et al. 2021. Measuring the Scope of Prior Authorization Policies – Applying Private Insurer Rules to Medicare Part B, JAMA Health Forum. 2021;2(5):e210859. doi:10.1001
4. Olson, et al. 2018. Cross-sectional survey of workplace stressors associated with physician burnout measured by the Mini-Z and the Maslach Burnout Inventory. Stress Health. doi: 10.1002/smi.2849
5. Prior authorization hurts patients, physicians, and employers. It’s time to #FixPriorAuth. 2021. FixPriorAuth.org. https://fixpriorauth.org/
6. Consensus Statement on Improving the Prior Authorization Process. 2021. AMA, AHA, APhA, AHIP, BCBS, and MGMA. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/prior-authorization-consensus-statement.pdf
