Most medical providers agree that prior authorization processes are overused, exploitative, and present both administrative and clinical concerns to physicians and patients alike.

A physician’s healing hands can be tied by prior authorizations:

Excessive prior authorization steps complicate clinical treatments. When a doctor and patient agree on what’s best for a patient’s health, many times additional, frustrating steps, including prior authorizations delay care. Despite patient health insurance coverage, the physician needs to predict the treatment options for the patient that will be approved. Both doctors and patients find the process exhausting.

Insurance companies want to avoid payment:

Prior authorizations were introduced years ago by health insurance plans. Generally, the prior auth applied to newly available medications, but in the past few years, the process has been extended to more treatments than ever before — including generic drugs. Doctors often deal with redundant paperwork and lengthy staff phone calls to ensure prescribed patient care. More medical procedures than ever are now affected with even decades-old, approved therapies experiencing rejections. Prior authorizations are up 23.9% from pre-pandemic levels, and assuming a practice pays staff at the 2019 rate, a provider’s office that spent $100,000 on prior authorizations in 2019, will pay an increased rate of at least 25% more today.

Patients and physicians are equally affected:

Doctors don’t have a say in the prior-authorization systems and are generally just as frustrated as patients. Patient satisfaction and staff morale both suffer as a result. Drugs and procedures that require prior authorization are constantly changing. Inappropriate rejections are common, and appeal processes are painfully slow and burdensome.

Despite all efforts by the requestor, insurers will simply take their time. A patient may be upset and wonder why they haven’t heard their therapy is approved. While most often the physician has done their part in completing requests and appeals and is waiting on the health plan to respond, patients should be encouraged to contact their insurance provider repeatedly, if needed.

Prior authorizations are a moving target:

Medications and procedures that require prior authorizations are now becoming a guessing game. No one can predict the specific information that will satisfy the insurer. The health plan employees assigned to evaluating the prior auth requests are most often not medically trained, and have no knowledge of the insured’s disease, or the prescribed treatment. Hours of time that could be spent caring for patients are instead wasted fighting appeals for care that is considered standardized.

Fighting rejections takes time:

Physician offices spend valuable resources responding to prior authorization rejections that prevent their patients from receiving prescribed treatments. The typical practice must respond to more than 50 weekly requests. The harmful reality behind the authorization debacle is that it delays essential patient care.

Many patients become upset, and simply walk away from care without treatment – but the insurers get exactly what they want because they didn’t pay. Ultimately, this practice increases the risk of poor medical outcomes, and increases hospitalization rates. As many as a third of patients facing a prior-authorization quagmire never receive their prescribed medications due to hurdles.

A disturbing truth is that health provider plans eventually relent with enough pressure and admit that the treatment is eligible for coverage and pay the claim. This is evidence that the health plan didn’t need to automatically deny the claim for services. Meanwhile, it may be too late for the patient.

Patients and providers who have worked on and found treatments that alleviate and cure disease, and are doing very well, can inexplicably be informed the insurance company has triggered an additional prior authorization requirement. When this happens, doctors must spend hours of time responding to requests to explain to the insurance company that the patient was thriving, and their disease had improved on the treatment. Still many times, this results in a rejection, despite clinical evidence. Essentially, insurers are telling doctors to take the patient off the effective medication, allow the patient to deteriorate — then they will consider approval.

Reducing your prior authorizations overhead with automation:

Many practices spend thousands of dollars annually on employees wasting time on hold waiting for payers to respond. Prior authorization rejections now cost physician offices more than ever, and many have resorted to hiring a dedicated employee to handle the task. Often, doctors fight repeatedly to get their patients the tests, medications, and treatments they need, and often win the battles when they are willing to fight. When treatable health care issues are not addressed in a timely way, patients are more likely to experience poor outcomes, and be hospitalized — so what is the insurance company recommending?  Generally, the cheapest alternative, and that’s typical. Previously covered services may no longer be available, solely because it benefits the payor.

Your time is better spent with patients, not on the phone:

As a provider, you know how manual authorizations can negatively impact your work schedule, revenue stream, and cause delays in patient care. At Virtual OfficeWare Health Solutions, our cycle management services eliminate that task so your team can focus on caring for patients and growing your practice. Working together, our authorization, and medical claims resolution services help your practice work more efficiently. You can reduce employee hours, including time spent researching requirements, tracking changes, calling payers for authorizations, and other administrative billing tasks.

Reduce staff burden and improve patient satisfaction now with our highly trained coders and billers who efficiently address your authorization issues using fully integrated automated claims services solutions prior to submissions, correcting, and resolving denial triggers to increase claims revenue.

Our billing management services take on the work so your staff can focus on caring for patients and improving your practice. Working together, our authorization management, and claims resolution services can benefit your bottom line. Through rules-based automation, the prior authorization management solution helps streamline processes to reduce the errors and delays that impact authorization speed, payment revenue, and patient experience. Let us handle the frustration of prior auth so your team can get back to what you do best — practicing medicine.