Medicare Advantage and the burden of prior authorization: Seeking a balance for patient care

by | May 12, 2023 | Blog | 0 comments

The growing administrative burdens associated with prior authorization requirements continue to frustrate patients and healthcare providers. In this blog post, we will explore the concept of prior authorization in Medicare Advantage plans, its impact on patients, and the need for a balanced approach to ensure optimal patient care.

Understanding prior authorization

Prior authorization is used by insurance plans, including Medicare Advantage, to determine if a specific medical service, procedure, or medication is medically necessary and covered by the plan. It requires healthcare providers to obtain approval from the insurance company before proceeding with the recommended treatment. The goal of prior authorization is to ensure the appropriate use of healthcare resources and control costs, but it often adds an extra layer of bureaucracy and delays in receiving care.

The burden on patients

While prior authorization serves a purpose, it can pose significant challenges for patients. The complex and time-consuming process can result in treatment delays, interrupting the continuity of care. It requires patients to navigate through administrative hurdles, obtain documentation from healthcare providers, and wait for approval, often causing anxiety and frustration. Moreover, patients with acute or chronic conditions may face health risks during these delays, exacerbating their medical conditions.

Impact on healthcare providers

The burden of prior authorization does not solely affect patients; it also places an enormous strain on healthcare providers. Physicians and their staff spend valuable time and resources navigating the prior authorization process, which could otherwise be spent on direct patient care. The administrative burden can lead to physician burnout and dissatisfaction, impacting the overall quality of care.

Striking a balance

While controlling costs and ensuring the appropriate use of resources is important, balancing these objectives and the patient’s timely access to necessary care is crucial. Here are a few steps that can be taken to alleviate the burden of prior authorization in Medicare Advantage plans:

1. Streamlining and standardizing the process

Implementing a standardized and simplified prior authorization process across Medicare Advantage plans can reduce administrative burden and create clarity for providers and patients.

2. Evidence-based guidelines

Developing evidence-based guidelines for prior authorization can help guide medical decision-making and minimize unnecessary delays. Clear and concise criteria for determining medical necessity would expedite the approval process.

3. Improved communication and transparency

Enhancing communication between insurance companies, healthcare providers, and patients is essential. Transparent guidelines and clear explanations of prior authorization requirements can help patients and providers navigate the process more effectively, reducing frustration and confusion.

4. Regular review and update

Regularly reviewing and updating the list of services and medications that require prior authorization can ensure that the process remains relevant and reflects current medical practices.

Medicare Advantage plans offer a range of additional benefits to seniors, but the burden of prior authorization remains a significant challenge. Striking a balance between cost control and timely access to care is crucial to ensure optimal patient outcomes. TRIARQ Health works with practices across different medical specialties to alleviate the burden on patients and healthcare providers by streamlining the prior authorization process, implementing evidence-based guidelines, embracing technology, and improving communication.

Ultimately, our goal is to help physicians prioritize patient care. Talk to one of our consultants today.