Prior authorization: Caught in an administrative nightmare

Michael A. Ferragamo, MD, a urologist and nationally known coding, billing, and reimbursement expert in the specialty, shared a story he said is just one example of the toll prior authorization is taking on urologists and their patients.

A patient presented with gross hematuria. The urologist wanted to do a cystoscopy then in his office, but couldn’t because the patient needed prior authorization for the procedure. About a week later, when the urologist obtained authorization from the insurer, the patient no longer had bleeding and was convinced he was OK and no longer needed the suggested examination.

The practice with which Dr. Ferragamo works called the patient repeatedly and tried to get him to come in for the procedure, to no avail. Six months later, the hematuria started again, as it often does when people have bladder cancer, according to Dr. Ferragamo.

“And a bladder tumor was found. If he had had the cystoscopy at the time he was in the office, without the delay, we would have seen the bladder tumor and treated it promptly,” Dr. Ferragamo said. “The insurance preauthorization started the ball rolling, but delayed proper care. Fortunately, the tumor was low grade and low stage.”

The process of prior authorization, also known as preauthorization or pre-approval, requires that doctors and other providers obtain approval from insurers before providing certain types of care, including prescribing medications and diagnostic tests.

Related: Inefficient payer approval processes fail patients, frustrate docs

According to the American Medical Association’s document, “Prior authorization: The current landscape,” health plans often use preauthorization to restrict access to costly services and therapies.

According to the insurance industry, preauthorization helps patients get the most effective and efficient care.

Ms. Donaldson“Health plans work with doctors and others to determine the best, most proven and most effective treatments for various conditions. This is particularly important when there are questions about efficacy of services or where there is a wide variation in how to treat a particular ailment,” said Cathryn Donaldson, director of communications and public affairs at America’s Health Insurance Plans.

“As drug costs continue to skyrocket, prior authorization can help ensure that patients are aware of treatments that may be as effective and less expensive. This, in turn, can lower out-of-pocket costs for the patient immediately, and for all Americans in the long run.”

Ask many doctors if they agree, and they don’t. They say they’re caught in the middle of an administrative nightmare while trying to provide quality care.

Next - Surveys: Prior auth burdensome, costly

Surveys: Prior auth burdensome, costly

Survey after survey points to prior authorization as among the inconveniences and costs to practices that hurt the profession most. In a 2016 AMA survey of 1,000 physicians, including 60% who were specialists, 75% classified prior authorization as a high or extremely high burden. Six percent indicated it was a low or extremely low burden. More than one-fifth of responding physicians said they and their staff spend more than 20 hours a week on prior authorization, and 23% said they complete more than 40 prior authorizations a week. Ninety percent reported delays in care due to the process.

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Statistics from a study published in 2013 suggest the cost of prior authorization for each full time equivalent physician is from $2,161 to $3,430 a year (J Am Board Fam Med 2013; 26:93-5), and stats from a 2011 study indicate yearly costs of a physician’s interactions with insurers is nearly $83,000 (Health Aff 2011; 30:1443-50).

Among urologists, prior authorization ranks as their second most pressing concern, according to Urology Times’ 2016 State of the Specialty survey. The same survey showed the problem is getting worse, with 86% of respondents reporting that prior authorization demands are increasing.

Urologists, in fact, are particularly hard hit. Many of the services urologists provide in the office, from drug therapy to procedures such as urodynamics and cystoscopy, require prior authorization, according to Dr. Ferragamo.

“More personnel is needed in the office just to do these authorizations. In our office, with five urologists, we have two secretaries that all they do, day in and day out, is get authorizations,” Dr. Ferragamo said.

Making matters potentially worse, a white paper by the Physicians Cardiovascular Disease Working Group published in late 2016 pointed to a North Carolina health insurance plan that requires physicians to pay $250 to file a second appeal.

According to statistics cited by the AMA, prior authorization requirements are growing. In the 2015 AMA presentation, “Break Through the Prior Authorization Roadblock,” presenters indicated there has been a 20% increase per year in drug prior authorizations.

Read: MedPAC proposals seek to mitigate Part B spending

All this, and prior authorization is not a guarantee of payment, even when a service or prescription is authorized.

Next: “You always feel like you’re being second-guessed."

Prior authorization is causing burnout, dissatisfaction, and early retirement in a specialty already experiencing a shortage of providers, according to Lane C. Childs, MD, a urologist with Summit Urology Group, Granger Medical Clinic, Salt Lake City, and chair of the National Insurance Advisory Workgroup, which is a workgroup of the AUA’s Coding and Reimbursement Committee.

Also see - ‘I can’t keep up’: Pay cuts, prior authorization take their toll

Dr. Childs“You always feel like you’re being second-guessed. You have to go through a lot of time-consuming calls and paperwork trying to get to a point where you can actually help patients,” Dr. Childs said. “We are absolutely forced to have our staff on phone calls-often on hold-filling out multipage forms, trying to make information available to insurers to give the green light to proceed with whatever sort of treatment.”

Dr. Childs said part of the frustration is the information is in the medical record or patient chart; why can’t the insurers just go there? Why, instead, do practices have to fill out several pages of forms, including, sometimes having to retrieve patient health information from prior years and different practices in order to get the OK to provide care?

“Assuming people are following guidelines and properly documenting the rationale for their treatment, then the information is in the clinical note,” he said.

That’s part of the problem, according to Mark Painter, CEO of PRS Urology in Denver. There is no standard approach or template for prior authorization. Not every plan handles prior authorization the same way, Painter pointed out.

A few tips for the short term

When it comes to really helpful things urologists can do now to ease the burden of prior authorization, there is very little to report.

Mr. PainterThere are some commercial applications that fill out prior authorization forms in an automated fashion for each payer, which can be used on existing electronic medical records. The companies that make the software charge from $2.80 to $5 for each prior authorization, based on the estimation that it costs a practice about $13 in hours and resources to do one prior authorization, according to Painter.

Another potential time-saver, according to Painter, is for practices to have several forms ready to go for each payer, so they can cut down on the search, find and print tasks, and allow a clinician to fill out what is needed without disrupting the patient flow. The trouble with that approach is that even though practices are still using fax and phone, all payers are moving toward electronic prior authorization. So, while the office may not submit the form, the office should be able to use the information to fill out the online version, he said.

“Most of the time, what you have to do is get on a website for the payer and fill things out and then submit it. There’s not a good way to do that, except to just do it,” Painter said.

Dr. Childs says urologists are more likely to get something approved if they talk with plans’ medical directors, physician to physician. But that’s not always feasible.

“I’ve invited patients to sit with me on the phone to go through the preauthorization process and that’s very effective. They can’t believe how lengthy and challenging it is. And then they go straight to their congressman,” Dr. Childs said.

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But educating one patient at a time is like trying to do a 180 in the Queen Mary, Dr. Childs said.

Next: Charging for prior auths

Some doctors are charging patients for preauthorization services. Estimates are around $20 for each preauthorization. In a March 2017 online poll by Urology Times, 31% of respondents report passing along costs associated with prior authorization to patients.

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Dr. KaufmanJeffrey Kaufman, MD, a urologist in Orange County, CA and past president of the AUA’s Western section, says his practice has not resorted to charging patients for prior authorization but has considered it.

“We’ve discussed the ethics and morals of it. Patients understand,” Dr. Kaufman said. “If I call my accountant and ask him to call the IRS on my behalf, I expect a bill.”

It’s reasonable, Dr. Kaufman said, for a patient to expect a bill if the doctor gets prior authorization for a treatment or medicine on the patient’s behalf.

Still, that’s something that the urologists interviewed for this article have a hard time grasping.

“The fact that physicians are considering billing for these services tells you that they are struggling, they are up against a wall, and they are feeling cornered that they have to make those kinds of choices to make ends meet,” Dr. Childs said.

Long-term solutions

The best shot doctors have at changing prior authorization is by lobbying at the state level, according to Painter.

“Most of the activity on trying to curtail the burden of prior authorization is happening at the state legislative level. And most insurance plans are regulated by the states and licensed by the states,” Painter said. (Also see, “Inefficient payer approval processes fail patients, frustrate docs” at urologytimes.com/AACU.) Groups have tried to negotiate with the payers, but that doesn’t seem to work, according to Painter.

“The best advice I can give is to get involved in the state medical association or the specialty medical association at the state level and work with them to develop laws within the state to reduce the burden on physicians,” he said.

On a national level, the AUA is supporting the AMA’s “Prior Authorization and Utilization Management Reform Principles,” which includes 21 principles for reform.

Read - Value-based pay in 2017: Where does urology fit?

While the principles are fair and reasonable and may streamline the process, Dr. Childs said, physicians will continue to be saddled with time-consuming prior authorization requirements, even if the principles are accepted by insurers.

Next: Non-profit hosts forum on prior authorization

The Galen Institute, a nonprofit organization focused on patient-centered solutions for health reform, is working to make patients more aware of how prior authorization could be blocking them from getting good care, according to Galen Institute President Grace-Marie Turner.

The Institute hosted a March 16, 2017 forum with physician leaders and patient advocates to raise awareness about the unprecedented interference blocking doctors from being able to prescribe the treatments they believe are best for their patients. The group plans to take what it has learned to develop policy recommendations and to educate the public on the need to put the doctor-patient relationship back at the center of the American health care system, according to a Galen Institute press release.

Ms. Turner“Doctors and patients must be at the center of the health care system,” Turner said. “But now there are people who have never and will never lay eyes on a patient making decisions about what care they receive, often overruling the judgment of physicians who have known and treated the patient for years. You can’t have a quality health care system with that kind of interference.”

Also see: Millennial urologists display a political awakening

One possible solution would be for the insurance companies to assume that most physicians are doing the right thing for their patients and to approve what is requested, according to Ronald P. Kaufman, Jr., MD, associate professor of surgery/urology at Albany Medical College.

“They could then focus on ‘outliers,’ based on the data that they have about individual physicians and how they practice, and only require prior authorization from these ‘outlier physicians’,” he said.

Dr. Childs said that in all his presentations on the topic, the comment that got a standing ovation from fellow physicians was one in which he suggested that physicians simply say “no” to the preauthorization process. He admitted the likelihood of such an uprising is small.

“If we just all said ‘no,’ and we didn’t do it anymore and referred people who want to know why we recommend drug X or procedure Y just to look in the patient record… I think people would hear us loud and clear,” Dr. Childs said.

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