Prior authorizations: How to choose the best approach for your practice

Jeffrey S. Williams

by Jeffrey S. Williams Jr., OD, Dipl ABO

In my conversations with other optometrists, I have found that most struggle with the demands of the prior authorization process.

Optometry is not alone in this challenge: According to a 2017 AMA Prior Authorization Physician Survey, a medical practice completes an average of 29.1 prior authorization requests per physician per week, which takes an average of 14.6 hours to process, or nearly 2 business days.

The impact on patient care is significant: More than nine in 10 physicians (92%) surveyed report that the prior authorization (PA) process delays patient access to necessary care, and nearly four in five (78%) say it can sometimes, often or always lead to a patient abandoning the recommended course of treatment (AMA).

The PA burden is currently a reasonable one for my staff and me, but that wasn’t always the case. When we handled PAs ourselves – specifically, I handled many submissions personally – the process had a significant, negative impact on both practice management and patient care. No matter how I tried to keep up with the forms specific to each patient’s insurance plan, their condition and the medication brand, I’d often find myself facing a denial and having to get on the phone with the plan. This invariably meant at least 45 minutes on hold – sometimes that long just to reach a person, and not always the right person at that, and with no guarantee I’d be able to turn the denial around. Critical delays were common and absolutely impacted patient care.

When PAs are denied, this means my patients aren’t receiving the medication I’ve deemed best suited to treat their condition, which in turn impacts clinical outcomes.

Sound familiar? If so, I recommend conducting an assessment of the impact of the PA process on your practice and taking a look at the approaches available to help you meet the challenge. Not sure where to begin? First, look at the factors impacting the scope of the PA challenge at your practice. These may include:

--How often are your prescriptions denied coverage because a PA is required?

--Are your patients’ managed care plans frequently changing the criteria for approving coverage for your prescribed medications?

--How important is it for your patients to receive the specific medication that you originally prescribed?

Next, assess the current burden on you and/or your staff in managing PAs:

--How many hours are spent on PAs including: Hunting for the correct PA form, completing and submitting the forms and spending time on the phone with managed care plans.

--How often are submitted PAs denied by the plan?

--If denied, how often does your practice appeal the decision with the plan?

Finally, consider your PA process options:

--Go it alone: This may require dedicating a member of your staff who focuses solely on PAs or carving out time from multiple staff members.

--Form-based service: These provide electronic access to forms from most plans for most products, either through a web portal or delivered from pharmacy. However, form layouts vary significantly by plan, and this type of service still puts the burden of interaction with managed care plan on the practice.

--Full-service provider: A full-service provider manages the PA process for the practice, including electronic submission of PA clinical information on common format, tracking down the patient’s prescription plan identification, follow-up calls to the plan and appeals support. This minimizes time required by the practice, as the service provider manages most time-consuming aspects of the process. In addition, this approach provides visibility into the PA process.

I made the decision to go with a full-service provider – in my case, PARx Solutions, which offers a free PA service to practices for many eye care medications. As a result, my practice efficiency has improved, and my patient care has improved, both in terms of being better able to get the medications I prescribe to my patients and in the additional time I now have to spend with my patients. Overall, I’d recommend utilizing a full-service provider to any medical practice struggling with the PA challenge.

Reference:

American Medical Association. 2017 AMA Prior Authorization Physician Survey. 2018. Chicago: American Medical Association. https://www.ama-assn.org/sites/default/files/media-browser/public/arc/prior-auth-2017.pdf. Accessed December 20, 2018.

For more information:

Jeffrey S. Williams Jr. , OD, Dipl ABO, practices at Sound Vision Care Inc. of Long Island, N.Y.

Disclosure: Williams reported no relevant financial disclosures.