Every doctor across every specialty has dealt with the headaches of prior authorization, and each has plenty of anecdotes about its adverse impacts on them, their staff, and, most importantly, their patients. While there have been serious attempts to change the system, most of the effects of these changes won’t be fully implemented for another few years. Independent practices can’t wait for years for this change when they feel the burden of prior authorizations now. So, how do you make prior authorizations easier today?
Your specialty practice can’t wait around for imposed deadlines to change broken prior authorization processes—you need solutions that benefit your practice today and prepare you for the future.
Prior Authorizations Have Wide-Ranging Impacts
Prior authorizations are more than just a day-to-day challenge. They create significant administrative burdens affecting time, profits, and patient care.
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Practice Impacts |
Patient Impacts |
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· Increased administrative burden · Time wasted dealing with inconsistent payment policies · Denial of routine items and services · Decision delays · Unnecessary resource strain · Physician and staff burnout
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· Limited doctor-patient interaction · Delays in needed care · Preventable adverse events · Seeking urgent/emergency care · Increased costs for care · Abandoning care altogether
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Where Prior Authorizations Started and Where They Are Going
Despite the negative feelings doctors and patients have toward prior authorizations, the reality is they aren’t going anywhere. But how did we get here in the first place?
How Prior Auths Got Out of Hand: A Brief History
Before prior authorizations, there was a process called utilization review (UR). This process was created in the early 1960s, along with the establishment of Medicare and Medicaid legislation. It was used to verify the need for hospital admissions by validating treatment based on a confirmed diagnosis with multiple physicians. The intention was to limit hospital stays, cut costs, and protect patients from receiving unnecessary treatments. Gradually, the process grew from physician burden to patient health risk.
Over time, utilization review evolved into the prior authorization system of today. While initially used to audit hospital admissions, it has morphed into a complex administrative process determining whether individual treatments are appropriate.
Where Prior Authorizations Are Headed
While the system has evolved, the goals have remained mainly the same. Payers want to contain their costs, and to accomplish that, they must maintain control over the care they pay for.
Not all prior authorizations lead to negative outcomes. There are some cases in which verification makes sense—but there are apparent issues with its current implementation. Payers and providers must come to a balanced agreement where costs can be controlled but treatment expertise is not infringed upon.
With All That in Mind, Here’s How to Make Prior Authorizations Easier
The elimination of the prior authorization process is extremely unlikely. However, given the copious hours of training that doctors and their staff undergo, they should be given the power to determine the right course of treatment. Significant reform is the solution to making prior authorizations easier across the board. Here’s how to make prior authorizations easier, starting with the most significant level of change and working toward a happy medium for payers and providers.
Significant Industry Reform: Gold-Carded Providers
The ultimate solution to prior authorizations involves payers and providers working together to create a system allowing automatic approvals for routine procedures based on provider metrics. The idea is that a physician with a track record of expertise (demonstrated through data metrics) would have the most common treatments they administer automatically approved through a gold-card status system.
A gold-card system would get us back to the original intentions of utilization review, reduce administrative overhead, control costs, and protect patients.
Ongoing Change: Optimize Practice Operations
It will take many years of collaboration for the gold-card process to become a reality—so in the meantime, practices should do what they can to improve processes and figure out how to start gathering these critical metrics. For most practices, this begins with building internal infrastructures to collect data across EMR, RCM, and other billing systems to support bidirectional data flow with payers.
The next step is to utilize those optimized processes to support value-based care and bundled payment programs. Practices that take the necessary measures to support these models are taking the required steps to support the goals of prior authorization. Using this to gather a deeper understanding of operations, practices could coordinate with payers to eliminate prior authorizations based on agreed-upon terms such as quality measures or for an entire episode of care.
In the long term, practices should determine how to optimize internal processes and data gathering and then use those tools to support value-based care and bundled payment programs.
Immediate Action: Find a Partner
If you feel like your practice is struggling with managing everything it takes to handle prior authorizations, you can take immediate action by working with a partner to reduce administrative burden. This allows your practice to:
- Increase the speed at which prior authorizations are submitted and resolved
- Acquire additional expertise for identifying risks and opportunities
- Gain performance insights based on metrics of similar specialty practices
- Reduce errors and operating costs through optimized processes
Seek out a partner who delivers the services you need and provides the reporting you need to evaluate their performance.
Looking for a Partner? We can help.
The key to alleviating the struggles around prior authorizations is to harness your data and then leverage it to tell the story you want to market to payers and referring providers. At TRIARQ, this is our main focus—and we can work with you across all parts of your practice to help you maintain your independence.
How TRIARQ Makes Prior Authorizations Easier
- Construct a data infrastructure that fits your practice’s needs to build internal data flows and interoperable data sets. We use this data to uncover the metrics that matter and develop an effective strategy to take on risk and improve practice marketability.
- Put that data to work to understand long-term data trends and how you compare to other similar specialty practices to create a comprehensive view of what your practice is doing.
- Tap into specialty expertise that uncovers opportunities for improvement and creates value. And while this includes prior authorizations, we leverage our expertise to optimize all components of practice performance management.
And what about Value-Based Care? We can also help build out those programs by leveraging your newly established data infrastructure to streamline prior authorizations and determine the metrics that matter within your practice.