AMA survey finds prior authorizations negatively impacts patients

Prior authorizations may be negatively affecting the workforce by interfering with patients’ jobs and sometimes leading to serious adverse events.

According to a news release from the American Medical Association (AMA), a survey of 1,004 practicing physicians found that 51 percent of respondents reported that the prior authorization process has interfered with their patients’ ability to perform their job responsibilities. A further 34 percent say that prior authorization has led to a serious adverse event such as hospitalization, disability, or even death for a patient in their care.

“Health insurance companies entice employers with claims that prior authorization requirements keep health care costs in check, but often these promises obscure the full consequences on an employer’s bottom line or employees’ well-being,” AMA President Gerald Harmon, MD, says in the release “Benefit plans with excessive authorization controls create serious problems for employers when delayed, denied or abandoned care harms the health of employees and results in missed work days, lost productivity and other costs.”

A vast majority of respondents, 93 percent, say that they’ve had to delay care while awaiting health insurer authorization of necessary procedures. A further 82 percent of respondents say they’ve had patients abandon treatment because of struggles getting authorization from health insurers, the release says.

When asked how often prior authorization criteria is based on evidence-based science or guidelines national medical societies, 30 percent of respondents say that the criteria is rarely or never based on these things. Only 1 percent of respondents say that prior authorizations have had a somewhat or significantly positive impact patient clinical outcomes, according to the release.

“Now is the time for employers to demand transparency from health plans on the growing impact of prior authorization programs on the health of their workforce,” Harmon says.

Here are some tips physicians can use to limit the impact of prior authorizations on their practice:

• Assign a staff member to each payer. This person can become an expert on the payers for which they are responsible, learning their specific expectations and what to avoid. They can also build relationships with their counterparts at the payer, which may help expedite claims and appeals. This person should also create a basic guidebook for each payer that others can follow if needed.
• Maximize the use of technology. Most payers offer online forms for the prior authorization process and some EHRs integrate directly with payer formularies. The more a practice can use these online forms, the more quickly an authorization can be obtained. In many cases, any missing information will be flagged before submission.
• Document all treatment decisions and back them up with evidence-based practices. Payer justification for prior authorizations is that physicians are not always following the latest evidence-based practices, so ensure all treatment decisions are based on the latest guidelines. If a prescription is not following the formulary, make sure all information as to why it is not is included in the prior authorization form.