The Prior Authorization Burden in Healthcare

In a world where information arrives and departs near instantly, a healthcare practice often feels like a juggling act of priorities. As insurance has grown to require ever more pre-authorizations from health professionals, the flood of requests can leave any physician feeling drained and lost. As stated in an article on MedicalEconomics.com, “Physicians are increasingly baffled by payers’ use of prior authorizations for what they say are often routine, low-cost treatments or for drugs that have already proven effective for years at treating a patient.”

Intended to be a safeguard against unnecessary procedures, prior authorizations have inadvertently become obstacles to a physician’s diagnosis and treatment. In fact, the preauthorization process can have surprisingly heavy impact on a patient’s health. The administrative demands of the process create an unnecessary burden on practices that are seeking to deliver evidence-based care in a timely way. Physicians have reported insurance pre-authorization measures could delay vital treatment, putting their patient at risk.  According to a survey conducted by the American Medical Association,
“Approximately 92 percent of physicians said that prior authorizations have a negative impact on clinical outcomes for patients, and 78 percent reported that prior authorizations can sometimes, often, or always result in patients stopping a recommended course of treatment.”

Cost is another issue.  A study by Health Affairs revealed that when the time is converted to dollars, practices spent an average of $68,274 per physician per year interacting with health plans. This equates to $23 billion and $31 billion annually! Prior authorization ultimately ends up costing the health care system more than it saves.

It’s clear that the pre-authorization system needs revision, so what can be done?

Electronic Prior Authorization-This enables healthcare professionals to easily obtain prior authorizations in real time at the point of care. In 2015, the average cost to a provider for an electronic prior authorization was $1.89 compared to $7.50 for a manual authorization.

Know insurer’s requirements–Check prior authorization requirements before providing services or sending prescriptions to the pharmacy to reduce patient delay.

Centralize the responsibility–Assign the task of prior authorizations to several people or an entire department, where that is their sole responsibility.

By seeking to simplify the prior authorization process, we may find better ways of achieving the Quadruple Aim of healthcare.  Unburdened by a mountain of approvals, our physicians would be free to pursue better care, improved health outcomes, lower costs, and enhanced clinical experiences.

Bendix, J., Krivich, R. S., Martin, K. L., Mazzolini, C., & Shryock, T. (2017). Top 10 challenges facing physicians in 2018. Medical Economics Blog, June 25 2017. Retrieved July 17, 2018, from http://www.medicaleconomics.com/editors-choice-me/top-10-challenges-facing-physicians-2018/page/0/3

LaPointe, J. (n.d.). 92% of Docs Say Prior Authorizations Negatively Impact Outcomes. RevCycleIntelligence. Retrieved July 17, 2018, from https://revcycleintelligence.com/news/92-of-docs-say-prior-authorizations-negatively-impact-outcomes

Leave a Comment