Ever since insurance companies entered the healthcare picture by way of employer-based insurance, medical treatment and prescription prior authorization (also known as pre-certifications and utilization reviews) have been an unwelcome but inevitable fixture in the care process.  What are they, why are they necessary and how can physicians minimize the stress and inconvenience that pre-certifications cause?

Prior Authorization Cost Physicians Time and Money

Most physicians and other providers agree that staff time spent on getting prior authorizations form insurance companies takes too much time out of a busy workday that could be spent on other necessary tasks. Unfortunately, a smaller practice’s billing and back office staff may already be stretched to the breaking point, so initiating and following up on “pre-certs” can sometimes be overlooked altogether – at least until a bill comes back as denied for reimbursement.

Here are some troubling statistics:

• Collective time spent by a physician’s staff is 14.6 hours on about 29.1 pre-authorizations per week.
• The average waiting period to hear back from the insurer is 10 business days (64 percent, of respondents) with those waiting 3-plus days at 30 percent.
• Over 84 percent of respondents say the wait period is too long.
• Missing authorizations – often due to clerical errors or not simply keeping up with changes in policies – account for 16 percent of first denials and 25 percent of denial write-offs, resulting in lost provider revenue.
• Physician stress and burnout is increased by the demands imposed by insurers, especially pertaining to pre-certs.
• By 2018, the increase in pre-certs has mushroomed to include many treatments, prescriptions and procedures, leading to controversies regarding who should make “medically necessary” decisions: those in the insurance companies’ executive suites or the healthcare providers.
• Payers build in “wait-time” into their workflow, which can result in adding as much as 48 to 72 hours just for response time.

What steps are some insurers taking to reduce wait times?

Some companies, such as Cigna, are trying to close the time gaps with improved technology that would pull information directly from the EHR. Jeffrey Hankoff¸ MD, Cigna’s medical officer for clinical performances and quality, states that using this technology reduces the need for the provider’s billing and other staff to have to select and submit the correct information needed to approve the pre-cert. While there are still some issues to be worked out, such as HIPAA clearances and information security, it could greatly speed up the process by resulting in fewer initial denials.

Some insurers may be willing to work out deals with practices, such as “gold card” or pre-approved deals on certain types of conditions or treatments requiring pre-authorization. These deals apply to practices that have demonstrated keeping costs low while performance high. Some, like Cigna, have noticed that giving a “free pass” to some practices may cause care quality to slip, so they want to see providers take on some risk as well.

Since one complaint of providers is that patients are often told one thing by an insurer regarding what’s payable, and the medical office is told something else, putting consistent, updated information on the insurer’s website available to both consumers and providers could be one way to avoid patient frustration and disappointment caused by miscommunication.

Patients Role in the Pre-authorization Process?

Providers need to educate patients that having insurance doesn’t mean that they will automatically receive an array of tests and treatments on demand. Evidence-based guidelines dictate that unless a given test or treatment is medically necessary, it won’t be covered, whether or not the patient is insured. An example is a patient demanding an MRI for back pain when more conservative, less expensive treatments would serve as well.

Pre-authorizations Process Guidelines

1. If possible, assign (or better yet, hire) a designated employee experienced in insurance processes handle the responsibilities for maintaining payer information, as well as updates in laws and regulations. Ideally, there should be full-time specialist for every 2-3 physicians, with the focus on payers covering the majority of a practice’s patients, enabling staffers to save more time.

2. One of the most common mistakes providers make at the administrative level is putting an inexperienced employee in charge of handling payer requests for information. A poorly-trained person often fails to send the necessary documents insurers require or perform timely follow up.

3. Create a system to process and track all pre-authorization requests from reviewing treatment documentation and plans to final follow-up. In a smaller office, responsibilities will need to be shared among all the staff, including providers, resulting in less time for treating their patients.

4. Electronic prior authorization processing speeds up the process and sharply reduces time wasted waiting for an answer. Manual submissions by fax, mail, phone or even email are the slowest and contribute to delays and mistakes.

The problem is keeping up with advances in billing – and pre-certification software in particular – is expensive and often not cost-effective for many smaller practices.

5. Providers can assign the pre-authorization process to a company experienced in all phases of billing, including prior authorizations, for a variety of payers and specialties. Look for a partner with access to cloud-based technology to stay current with rapid changes, full transparency, clinically-trained experts and full-service support.

6. Consider partnering with an outside billing and practice management service.

Billing services, such as those offered by M-Scribe, have access to top-flight technology for creating and documenting pre-authorizations giving payers everything they need to make a reimbursement decision from the onset. Our experienced billing and claims management professionals know what kind of documentation and other information insurers are looking for, as well as checking for contractual regulations and updates.

Contact me at 770-666-0470 or by email for a free consultation and  of your practice’s revenue management needs. Learn how we can help you take charge of your pre-authorization processes for shortening approval time while improving reimbursement levels to meet your financial goals.

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