Author: Steve Fields, Vice President – Field Access & Reimbursement, Inizio Engage

Prior Authorization is a healthcare protocol used by insurers and payers to determine coverage for prescribed medications or services. This process requires providers to obtain approval from a health insurance company before delivering specific therapy to ensure the treatment is medically necessary and falls within the coverage guidelines.

Prior Authorization (PA) serves as a checkpoint that ensures healthcare resources are used efficiently, preventing unnecessary procedures and reducing the incidence of costly over-treatment. For healthcare professionals, this means less time dealing with complications from inappropriate therapies and more focus on delivering suitable treatments. Studies found that PA protocols can reduce hospital readmission rates by ensuring patients receive optimal initial care, saving significant costs and resources in the long term.1 By requiring a review of the planned care approach, PA’s prompt a reassessment of the initial diagnosis and treatment plan. This review process helps in “fine tuning” treatment plans to align more closely with the latest clinical guidelines and patient-specific factors, thereby improving outcomes.

Prior Authorization: Challenges and Opportunities in Healthcare

Prior authorization presents both challenges and opportunities for healthcare professionals and organizations. Physicians often find themselves spending a considerable amount of time navigating the PA process, diverting precious hours away from patient care. According to a report by the American Medical Association (AMA), physicians and their staff spend an average of 14 hours each week on prior authorizations.2 35% of physicians have staff who work exclusively on prior authorization, and 80% of physicians report that the number of prior authorizations required for prescriptions and medications and medical services has risen over the last five years.2 This administrative burden can be cumbersome and frustrating for both physicians and their staff, leading to delays in care coordination and impacting patient satisfaction. This increases the need for skilled prior authorization specialists in order to decrease the administrative burden that prior auths can bring in an office.

Pharmacists also encounter hurdles in the PA journey. From identifying the need for prior authorization to waiting for approval from payers, the process can be time-consuming and cumbersome. Moreover, the uncertainty surrounding PA approvals can disrupt the workflow of pharmacies, impacting the efficiency of medication dispensation.

Impacts Across Healthcare Stakeholders

This administrative burden not only affects physician morale but can also lead to delays in patient care and treatment. Pharmacists encounter hurdles in the PA journey. From identifying the need for prior authorization to waiting for approval from payers, the process can be time-consuming and cumbersome. Moreover, the uncertainty surrounding PA approvals can disrupt the workflow of pharmacies, impacting the efficiency of medication dispensation. Payers, on the other hand, face the challenge of balancing cost containment with ensuring patients receive medically necessary treatments. The decision-making process behind prior authorizations involves evaluating clinical guidelines, treatment algorithms, and cost-effective analyses to determine the appropriate course of action.

For patients, prior authorizations can be a stepping stone to accessing newer, more expensive treatments that might otherwise be inaccessible due to cost constraints. Insurers are more willing to cover costly therapies if their efficacy and necessity are thoroughly validated before approval. This process ensures that all stakeholders such as payers, providers, and patients are confident in the treatment plan, which can lead to better adherence and outcomes.

Patients often face high out-of-pocket costs for advanced medications without insurance coverage. PAs helps to ensure that the treatments covered are within the insurance policy’s terms, potentially lowering the cost burden on patients. By confirming the medical necessity of procedures and treatments, PA helps protect patients from unexpected medical bills for non-covered services.

Financial Implications of Prior Authorization for Healthcare Providers

Prior Authorization directly impacts the financial health of healthcare providers by securing insurance reimbursements. By obtaining insurance approval before proceeding with treatment, healthcare providers mitigate the risk of denied claims and delayed payments, which can significantly affect their revenue stream.

Despite the challenges posed by prior authorization, its implementation serves a critical purpose in the healthcare ecosystem. By requiring healthcare providers to obtain approval before prescribing certain treatments, PA helps ensure that patients receive appropriate and medically necessary care. This process not only safeguards against unnecessary or excessive treatments but also promotes the rational use of healthcare resources.

Moreover, prior authorization can contribute to improved patient outcomes by encouraging providers to consider alternative treatment options and explore cost-effective alternatives. By engaging in a dialogue with payers and adhering to evidence-based guidelines, healthcare professionals can make informed decisions that prioritize patient well-being.

Effective PA processes can also reduce administrative burdens by decreasing the need for rework and claims appeals. Automating PA requests and approvals can save significant time and resources, allowing healthcare staff to focus more on patient care rather than administrative tasks. This efficiency not only improves job satisfaction among healthcare professionals but also contributes to the overall financial stability of healthcare organizations

The Role of Field Reimbursement Managers (FRMs) in Prior Authorization

Field Reimbursement Managers (FRMs) play a crucial role in this process, serving as liaisons between healthcare providers and payers. By educating HCPs on reimbursement policies, assisting with coding and billing requirements, and advocating for patients through patient assistance programs, FRMs facilitate the reimbursement process and ensure that providers receive timely payments for their services. Many FRMs within the pharmaceutical industry explore opportunities to better educate their HCPs and stakeholders on reimbursement challenges such as prior authorizations. In order to build their expertise, many FRMs become certified in the field.

This discussion on the importance of prior authorization resonates deeply with the objectives of the Prior Authorization Certified Specialist (PACS) program. This accredited program enables stakeholders in the prior authorization process -pharmacists, providers, FRMs, etc – to become skilled experts by enhancing their knowledge on the process from multiple perspectives, including the patient. Through the PACS program, stakeholders can collaborate to develop and implement strategies that enhance the efficiency and effectiveness of prior authorization, ultimately benefiting patients, providers, and payers alike. By shedding light on the challenges faced by healthcare professionals and organizations in the prior authorization process, this blog post underscores the need for innovative solutions and streamlined workflows.

In conclusion, prior authorization serves as a cornerstone of the healthcare system, balancing the needs of patients, providers, and payers. Despite the challenges it presents, PA plays a vital role in improving patient access to medications and services, streamlining reimbursement processes, and maximizing revenue generation for healthcare organizations. By understanding the importance of prior authorization and leveraging effective strategies to navigate its complexities, healthcare professionals can enhance the quality of care delivered to patients and optimize the financial health of their organizations.

Sources

  1. Farhat NM, Vordenberg SE, Marshall VD, Suh TT, Remington TL.
    Evaluation of Interdisciplinary Geriatric Transitions of Care on Readmission
    Rates. J Manag Care Spec Pharm. 2019;27(7)
  2. American Medical Association. Fixing Prior Auth: 40-Plus Prior
    Authorizations a Week Is Way Too Much. Accessed May 2, 2024. Available
    from: https://www.ama-assn.org/practice-management/prior-
    authorization/fixing-prior-auth-40-plus-prior-authorizations-week-way-too