Streamlining the Prior Authorization Process

One of the administrative burdens that physician practices are facing today is prior authorization requirements. Many health plans employ highly manual, time consuming processes that utilize the telephone, fax and web portals to transmit authorization requests and forward supporting documentation.

Prior authorization programs require that a health plan’s medical necessity guidelines are met based on a patient’s diagnosis and history. In an effort to insure that the services are provided in the most cost effective manner, health plans will request treatment plans and the expected CPT code for the service requested, prior to authorizing the service.

There are modern technologies and standards being developed to automate this manual process and reduce the cost. Practices are encouraged to take advantage of implementing some of the following suggestions:

• Chart major health plans authorization requests and develop a list of pre-approved medications to reduce requests and save time.

• Check to see if any of your health plans offer prior authorization waivers for clinicians who meet certain benchmarks.

• Assign prior authorization responsibilities to designated staff to improve efficiency; particularly in large practices.

• Develop a process to address denied authorizations. It should include a well-constructed appeal that includes all supporting documentation.

• Complete all prior authorization requirements before submitting prescriptions to minimize calls from pharmacies.

• Assign staff to monitor prior authorization approval and to follow up with health plan if a request is delayed or lost.

• Check with your EHR vendor regarding your software capabilities of auto-populating prior authorization request forms that can reduce administrative time.

• Consider the use of a health’s plan web portal instead of opting for phone or fax interaction while handling a prior authorization.

• Test implementation of electronic prior authorization with pharmacies first, before moving to other medical services.

• Conduct a return on investment (ROI) on your low volume health plans that have high prior authorization requirements. It might be less costly to drop these plans.

• Discuss electronic prior authorization options with your practice management system and EHR vendor.

Robert Tenant, M. (2016). MGMA staff member. Connection, 26-30.