Pre-authorizations: Bureaucratic nightmare, harmful to patient care

Pre-authorization (PA) eats up extensive resources and requires manual input that diverts valuable time away from treating patients. PA can postpone treatment and contribute to negative clinical outcomes, according to the AMA.^[] The AMA has been lobbying to decrease the negative impacts of PA on patients and physicians, but these changes won’t be immediate.

These reforms promote efficient and affordable access to evidence-based care for patients, while minimizing administrative red tape. For now, however, physicians can minimize the inconvenience of PA and help secure approval by following certain tips.

The PA process

After receiving a PA request, insurers will typically respond in 5 to 10 business days. They will either approve the request, deny it, request more information, or recommend less costly alternatives.

Insurers’ responses are based on input from physicians and pharmacists employed by the insurer. The physician or patient can appeal PA decisions.

On its website, insurer Cigna claims PA decreases treatment costs by necessitating that lower-cost alternatives be tried first.^[] It also decreases the risks of drug interactions and curbs the use of unnecessary treatments or addictive medications, according to the insurer.

“The sheer volume and burden of prior authorization requirements, imposed by insurers with virtually no transparency, harms patients, undercuts clinical decision making, and wastes valuable healthcare resources,” said AMA President Jack Resneck Jr., MD, in an interview with MDLinx.

Problems with PA

Common physician gripes about PA include that the process is arduous and distances patients from their care.

“In practice, insurers eventually authorize most authorization requests, but the process can be a lengthy administrative nightmare of recurring paperwork, multiple phone calls, and bureaucratic battles that can delay or disrupt a patient’s access to vital care,” said Dr. Resneck. "Some patients, frustrated with the wait and confusing process, abandon their treatment."

Dr. Resneck points out recent research that shows PA is not evidence-based. “While insurers have said the policies reflect evidence-based medicine, physicians disagree. Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices."

“In the most recent AMA survey, only 15% of physicians reported that prior authorization criteria were often or always evidence-based,” he said. 

Dr. Resneck noted the undue rigors of PA can also stress out physicians.

“Physicians who feel over-scrutinized and overburdened with overused prior authorizations can suffer continually from a growing sense that they are neglecting the professional priorities that really matter: their patients," he said.

"Forced to devote substantial time and resources to clear insurer-imposed administrative hurdles, physicians feel powerless and wholly unable to provide patients with timely access to evidence-based care."

What’s being done

Left to their own devices, it’s unlikely that insurers will work to change the PA status quo.

“Despite mounting evidence that insurer-imposed authorizations for drugs and medical services can be a hazardous and burdensome administrative obstacle to patient-centered care, most health insurers continue to show apathetic or ineffectual follow-through on mutually accepted reforms,” said Dr. Resneck.

Instead, the AMA has been actively lobbying to reform PA and educate its constituent members regarding PA.

Dr. Resneck said the PA reform momentum feels “powerful,” noting 90 bills in 30 state legislatures as of 2023, with advocates laying the groundwork for next year. “These state efforts join major federal-level reforms being proposed and finalized,” he said.

“Policymakers and other stakeholders seem to be realizing what patients and physicians have known for a long time—prior authorization harms patients, undercuts clinical decision making and wastes valuable health care resources.”

Dr. Resneck said that the AMA and other physician organizations are calling on state and federal lawmakers to follow through on proposed reforms, noting the health insurance industry’s lack of progress toward the reforms outlined in the 2018 consensus statement.

Dr. Resneck advised that physicians visit the AMA website for more guidance on dealing with PA.^[] “While the AMA continues to work on every front to reform prior authorization, we do offer physicians a series of tools and resources to help minimize the current impact of prior authorization on practices.

The AMA’s tips on facilitating an effective PA process

The AMA offers five useful tips on how physicians can more efficiently and effectively navigate PA:

1. Check on PA requirements before prescribing or treating patients. This will help prevent denials or forfeited payments while minimizing prescription delays and decreasing patient non-adherence.

2. Establish the practice of entering all documentation needed for a PA in the patient’s chart. This will minimize the physician’s PA involvement, as other staff members could retrieve the information and prepare the PA. Having complete information also reduces the need for another patient visit to fill in missing data.

3. Select the PA option that’s most efficient based on insurer options. 

4. Follow up with payers to make sure the PA request was received and is on track. Make sure no forms are lost or delayed.

5. When PAs are denied, physicians should try to submit organized, concise, well-written appeals, which can boost approval success rates and minimize potential delays. 

An FPM blog posting offered the following additional tips:^[]

• Formulate master lists of medications and interventions that require PA. Break them down by insurer, and program your EHR system to flag anything requiring PA.

• Delegate certain staff to handle PA. This makes them experts and expedites the process.

• Use pre-populated forms for PA as needed.

• Use the insurer’s own forms, listing codes, and diagnosis conventions. Use online forms to make the process faster; getting PA over the phone is usually very time-consuming.

• Rely on evidence-based guidelines when pursuing PA. 

• Seek out lower-cost alternatives that may not need PA. Opt for generic drugs, which usually don’t require PA.

• Use the insurer’s peer-to-peer process and engage its physicians or medical directors to address your questions.

• Make sure your patients understand the PA process and coverage limitations. By educating them, they’ll direct frustration regarding denials toward the insurer, which could facilitate change.

• For a denial, defend your position vigorously by sending letters supporting a patient’s need for certain medications and the dangers of switching them.