How do prior authorizations affect your practice?
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Avoid the process
Health insurance companies use prior authorization processes to lower payer costs.
The problem is that prior authorizations (PAs) interfere with the patient-physician relationship; delay or prevent access to treatments already covered by an insurance plan for which the patient has paid; and create a significant administrative burden for physicians. According to the AMA, physicians complete an average of 41 PAs per week, consuming 13 hours of staff time.
One way that refractive surgery practices like ours have responded to this is to opt out of the PA process. When choosing postoperative eye drops for the six surgeries we perform — LASIK, PRK, SMILE, Visian ICL (STAAR Surgical), Kamra (CorneaGen) and refractive lens exchange (RLE) — our staff consulted with St. Louis pharmacies and local insurance plans. Starting with a list of our preferred medications for each procedure, we were pleased to find that we could assemble complete postoperative drop regimens from medications not subject to PA.
We are fortunate as ophthalmologists to have a wide variety of generic, locally compounded and mail-order medications to choose from. If a patient had significant dry eye 10 years ago, ophthalmologists had no choice but to process PAs for Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) due to a dearth of alternatives. Over the past decade, the number of options has expanded greatly. When dry eye or elevated IOP is encountered in routine postoperative care, we can prescribe generic or compounded cyclosporine and choose from a dozen effective IOP-lowering medications not subject to PA.
When it comes to IOL surgery, I have long been impressed by the degree to which the insurance definition of cataract is arbitrary. Patients begin to experience measurable changes in their crystalline lens in their 40s when they enter dysfunctional lens syndrome (DLS) stage I. The aging lens contributes, in part, to loss of near reading vision and development of higher-order aberrations. When patients move through their 50s and 60s, DLS stage II sets in. At this stage, we observe degraded vision associated with forward light scatter as well as decreased contrast sensitivity and night vision, even though patients may correct to 20/25 or 20/20.
Many patients do not want to spend years watching unaided eyesight decline as they go through these stages, let alone meet the payer’s definition of the billable cataract that comes with DLS stage III. For those seeking an alternative, preemptive IOL surgery in the form of RLE, increasingly performed bilaterally in office surgery suites, has proven valuable and highly popular. Surgeons should give greater consideration to RLE for patients with DLS. RLE bypasses an insurance process that, as we will increasingly learn, may not be ready to help the patient when the patient is ready. Even if visually significant cataracts are present and help is found, PA may delay visual rehabilitation.
Our colleagues providing care for some ophthalmic conditions may have no choice other than to prescribe medications subject to PA. One important step we can all take is to urge employers to scrutinize PA processes when making yearly buying decisions on the health plans they offer.
Jason P. Brinton, MD, is an OSN Refractive Surgery Board Member.
A lot of work for the office
Prior authorizations are an important topic, as there is a lot of work involved.
There are two categories: medications and procedures. Either way, you have to go through a process, and then there is a chance it will be rejected.
We have a full-time staff member in which one of her primary responsibilities is to obtain prior authorizations. It might just be almost a full-time job. Authorizations for surgical procedures such as corneal collagen cross-linking, phototherapeutic keratectomy or other intraocular procedures as well as medications such as those for dry eye, inflammation or IOP control need to be obtained daily. The burden this time commitment puts on our practice is tremendous, but the concerning aspect is that not only is this a large time commitment on the staff, who are doing their best to help, but patient care is ultimately affected as it is not infrequent that either the authorization is declined or a change to the patient care has to occur. Patient care is then negatively affected because sometimes they do not get the medication they need.
In addition, to make matters considerably more difficult, the patients get frustrated, so they start calling the office. Our call volume increases. These issues might tie up the phone and technicians, and then more time and frustration may incur.
Ultimately, prior authorization can change the patient care. We can be strong armed to change to change the patient’s treatment based on insurance coverage. You will not necessarily get to do the treatments you were planning to do, and that leads to changing the course in some situations.
Kathryn M. Hatch, MD, is an OSN Technology Board Member.
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