Good, bad, and ugly: Prior authorization and medicolegal risk

Some practitioners charge patients for time spent completing PAs.²³ Although phy­sicians should “complete without charge the appropriate ‘simplified’ insurance claim form as a part of service to the patient;” they also may consider “a charge for more complex or multiple forms … in conformity with local custom.”²⁴ Legally, physicians’ contracts with insurance panels may pre­clude charging such fees, but if a patient is being seen out of network, the physician does not have a contractual obligation and may charge.⁹ If your practice setting lets you choose which insurances you accept, the impact and burden of seeking PAs is a factor to consider when deciding whether to par­ticipate in a particular panel.²³

In an interesting twist, an Ohio physi­cian successfully sued a medical insur­ance administrator for the cost of his time responding to PA inquiries.²⁵ Reasoning that the insurance administrator “should expect to pay for the reasonable value of” the doctor’s time because the PAs “were solely intended for the benefit of the insur­ance administrator” or parties whom the administrator served, the judge awarded the doctor $187.50 plus 8% interest.

Considerations that are more practi­cal relate to how to triage and address the volume of PA requests. Some large medi­cal practices centralize PAs and try to set up pre-approved plans of care or blanket approvals for frequently encountered con­ditions. Centralization also allows one key administrative assistant to develop skills in processing PA requests and to build rela­tionships with payers.²⁶

The administrative assistant also can compile lists of preferred alternative medica­tions, PA forms, and payer Web sites. Using and submitting requests through payer Web sites can speed up PA processing, which saves time and money.²⁷ As electronic health records improve, they may incorporate patients’ formularies and provide automatic alerts for required PAs.²³

Patients should be involved, too. They can help to obtain relevant formulary infor­mation and to weigh alternative therapies. You can help them understand your role in the PA process, the reasoning behind your treatment recommendations, and the delays in picking up prescribed medications that waiting for PA approval can create.

It’s easy to get angry about PAs
Your best response, however, is to practice prudent and—within reason— cost-effective medicine. When generic or insurer-preferred medications are clini­cally appropriate and meet treatment guidelines, trying them first is sensible and defensible. If your patient fails the initial low-cost treatment, or if a low-cost choice isn’t appropriate, document this clearly and seek approval for a costlier treatment.⁹
 

BOTTOM LINE
Physicians have ethical and legal obligations to advocate for their patients’ needs and best interests. This sometimes includes completing prior authorization requests. Find strategies that minimize hassle and make sense in your practice, and seek efficient ways to document the medical necessity of requested tests, procedures, or therapies.
 

Acknowledgment
Drs. Marett and Mossman thanks Donna Vanderpool, MBA, JD, and Annette Reynolds, MD, for their helpful input in preparing this article.

Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.