Managing Your Practice

Dealing With Prior Authorization


Since passage of the health care reform bill in March, there has been considerable discussion in medical periodicals, forums, and blogs about the dramatic changes that will be taking place.

At least one thing—prior authorizations—will not change, because the legislation did not address it.

Lawmakers have offered no public explanation for ignoring such a glaring problem. It should have been obvious, even to them, that requiring physicians to ask permission, over and over, for necessary tests and treatments is senseless and inefficient.

Common sense dictates fixing something so universally hated by doctors and patients alike. One can speculate that the third party in the physician-patient equation—insurers—had a lot to do with this oversight.

Insurers love prior authorization because it saves them money. In fact, it's one of the most effective cost-cutting tools in their box: rationing through inconvenience. So it's logical to speculate that they probably used their considerable input into the reform law's content, via their army of lobbyists, to discourage action.

So, prior authorization will remain a problem for the foreseeable future, and we need to deal with it as best we can.

First and foremost, minimize the wasted time prior authorizations cause you and your staff. My office took a major step toward this goal by banning all submissions by telephone.

A single prior-authorization phone call can easily take 30 minutes of staffers' time as they fight through the automated greetings and category selections, and wait on hold before finally speaking to somebody with a pulse. At that point, since the person is hardly ever authorized to give approval, they get another department's number or a faxed form. It's an inexcusable and outrageously expensive waste of time.

When a request for preauthorization comes in, we call the patient and ask that he or she make the call to the insurance company to request the form.

I have mixed feelings about passing along the automated phone-hoop hassle to patients, but it is their insurance, after all, and this is one area where I simply can't afford the luxury of providing a time-consuming service for free. Plus, it gives patients some understanding of the absurdity of the whole prior-authorization game.

When possible, we enlist the help of any other parties at our disposal. Some insurers will accept prior-authorization requests from pharmacies, which makes a lot of sense. They typically have a complete record of all medications tried and failed, as well as the necessary diagnosis codes.

Unfortunately, many insurers inexplicably insist that only the physician's office submit the request, but it's worth your time to ask if the company in question accepts pharmacy filings, rather than assuming it doesn't.

Also, don't forget that manufacturers of some medications (biologics, for example) will help with some, or all, of the prior-authorization burden. Sometimes they have an auxiliary company set up just for that purpose.

If not, a representative or district manager may be able to help or point you toward someone who can. It never hurts to ask.

Also, most pharmaceutical companies have a “compassion” program that provides medications free when the insurer will not pay and the patient can't afford it.

Other potential allies are the big-box chains that offer selected medications at $4 (or less) per prescription. Sometimes, the most efficient solution is to point the patient toward Walmart, Costco, Target, or another chain in your area, and forget the preauthorization altogether.

The key is to get the insurance company's form. Not only do you avoid the phone runaround, but the form tells exactly what that particular company wants, so your staff won't waste time finding and supplying information that is not needed.

What about patients who request prior authorization for medically unnecessary medications?

In my office, that's usually a retinoid prescription for wrinkles. I tell them it's against the law to say a treatment is necessary when it is not, and that there is zero chance their insurer will pay. (As a diplomatic friend of mine puts it, “Your insurance company barely cares if you are dying, let alone how you look!”) I tell them I will not be able to go to bat for older patients with recalcitrant acne who really need retinoids, if I try to slip cosmetic prescriptions past insurers. Most understand.

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