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Experts recommend reviewing prior authorization policy for skin biopsies

Research is needed to address the utility and impact of prior authorization for skin biopsies, according to three authors of a recent opinion paper in JAMA Dermatology.

“Although prior literature and organizational advocacy efforts have focused on the application of [prior authorizations] to pharmaceuticals, little attention has been paid to the use of [prior authorizations] for in-office procedures, including diagnostic skin biopsies,” Andrew T. Rogers, BS, Brittany Sutherland, MHA, and Manisha J. Loss, MD, all from Johns Hopkins University School of Medicine, Baltimore, wrote.

The authors added that 40% of health plans at Hopkins require prior authorization for biopsies, and that there is no record of this request being denied. “This is unsurprising given that biopsies are used for confirmatory diagnosis of an uncertain skin condition, such as a neoplasm of uncertain behavior, leaving payers without a clinical basis to deny such procedures,” they wrote. “This is in contrast to [prior authorizations] governing the use of pharmaceuticals, in which case payers may be able to cite clinical guidelines to justify requirements that physicians prescribe less expensive therapies before more expensive ones.”

From this information, they suggested that prior authorizations may impact patient experiences with health care and add to resource utilization, including the administrative burden required for authorization. Direct costs to the patient and insurer are involved, including copays, coinsurance or deductibles. Additional office visits may be required. “Prior studies have suggested that the annual per-physician cost of interacting with payers to obtain [prior authorizations] can be as high as $25,000,” they wrote. In addition, requiring prior authorization may increase wait times for patients who adhere to their return visit, which causes patients to lose work time. Patients are also more likely to be lost to follow-up when prior authorization is required, which can impact outcomes, according to the authors.

“[Prior authorizations] for biopsies negatively impact quality of care in many ways,” the authors added. “Care is less patient centered, less timely and less efficient because patients are expected to return to the office at a later date.”

The prevalence of prior authorization for skin biopsies should be evaluated in clinical trials, as should the cost-benefit ratio, the authors wrote. “Payers should contribute to this research effort because they have data that would justify their policies,” they wrote. “Although some may view [prior authorizations] as cost-saving measures in the case of therapeutic interventions, [prior authorizations] for diagnostic skin biopsies do not appear to be achieving this purpose and may be leading to unintended negative consequences for patients.”

The authors acknowledged that prior authorization may reduce the number of procedures performed, and therefore be associated with a cost savings. “It is also possible that payers eventually intend to deny [prior authorizations] for skin biopsies but are first creating the expectation of [prior authorizations] as an incremental step toward this future goal,” they wrote. “In any case, the rationale for these [prior authorizations] remains dubious. To the extent that there remains a justifiable need for payers to manage biopsy decision-making, more effective and less burdensome alternatives to current [prior authorization] processes should be considered.” – by Rob Volansky

Disclosures: The authors report no relevant financial disclosures.