Keeping payers, other third parties from interfering with patient care

This article appears in the 4/25/18 issue of Medical Economics.

Primary care physicians say they find their practices increasingly beset by outside interference that gets in the way of effective patient treatment. 

When asked about the main problem facing primary care today, 70 percent of physicians tagged “third-party interference” as the biggest challenge, according to the Medical Economics 89th Annual Physician Report. 

Most physicians in the study pointed to prior authorizations as the most common type of interference they experience. But that is only the beginning, says Ripley Hollister, MD, a primary care physician who operates Hollister Healthcare Team in Boulder, Colo.

After thinking about the various sources of interference physicians deal with Hollister came up with an extensive list: prior authorizations and narrow networks from private payers; government mandates, regulations, and attestation requirements; quality metric and certification obligations; hospitals; EHR vendors; and physician advocacy groups. The list goes on.  

“Third-party interference is burning doctors out because we want to take care of patients,” says Hollister, who also serves as a board member for the Physicians Foundation, an advocacy group for practicing physicians. “Doctors enjoy the intellectual challenge, the compassion, the relationships; that’s why we went into medicine. And all of these things get in the way.”

“It has nothing to do with medical care,” adds Kenneth Kubitschek, MD, an internist in Asheville, N.C. “It’s all about saving money and putting people through the hassle so they get tired of the hassle.”

Physicians interviewed by Medical Economics say there are ways to minimize the pain and take a stand, however. They range from small workflow tweaks to more drastic changes such as dropping a payer or switching to a practice model such as direct primary care that cuts insurance companies out completely.

Next: Workflow changes

Workflow changes

Prior authorization for prescription drugs is the most common form of third-party interference practices experience, physicians say.

At Ravenna Family Practice in Ravenna, Mich., Nicholas Beechnau, DO, and his father, Timothy Beechnau, DO, have a small staff so they try to stay on top of what their major payers require to avoid unnecessary call-backs. “You start to learn what they require for the next test,” says Nicholas. “The problem with all the different payers is that they all have different hoops.”

That can quickly get complicated. Requirements and formularies are constantly changing. There is rarely, if ever, any notice when these changes occur. Doctors typically learn about a change only when coverage is denied. “It’s never steady ground you’re standing on; it’s always a moveable world,” Kubitschek says.

Kubitschek’s 17-provider practice has a staff person dedicated to handling prior authorizations and learning the “hoops they need to jump through,” Kubitschek says. The key is having someone who can monitor the most important payer contracts, track denials and pre-approval requests, and communicate changes to the physicians and providers as they come up, he adds.

Another option is to put the onus on patients to call the insurance company for authorizations, Kubitschek says. While his practice will complete any forms the patient needs to send to their insurance company for approval, staff members will not make the calls.

“We put it back on the patient,” he says. “You can’t take on everything when they [the insurance companies] are putting up barriers more and more. If patients don’t feel that pain with us, the insurance company will say, ‘Why not put up more barriers?’ We have to let the patients know that their insurance companies are being unreasonable.”

It’s important to explain to patients the reason for this policy, Kubitschek says. His practice has a script that employees can use to make sure they explain the issue thoroughly, answer questions and address any complaints. 

There have been some changes for the better, Kubitschek says. His practice’s EHR recently acquired the ability to do e-authorizations, which has the potential to streamline the approval process somewhat. “We’re excited about it,” he says. “It fills out part of the form for you, the demographics of the patient. We just started using it and I think it’s going to be a big plus for us.”

Next: Fighting back

Fighting back

But sometimes a payer’s requirements, denials, and authorization demands become so onerous there’s only one option: Stop working with that payer.

Kubitschek’s practice recently jettisoned a payer that had become too difficult to work with. He advises that it’s not a decision to make lightly, as it will affect patients and could impact the practice’s bottom line. But practices shouldn’t be afraid to make it under the right circumstances.

“Know your payer mix, and know when you need to fish or cut bait,” he says.

An even more radical step is to stop taking third-party payments entirely. Among the most common ways practices do this is to adopt the direct primary care model, in which patients pay a monthly fee that covers all their routine medical care.

Hollister, with the Physicians Foundation, says direct primary care offers a route to a kind of freedom that puts patient care first. “We want to take care of the patient, but we’re taking care of the insurance company,” he says. “One of the solutions is to do whatever you can to get rid of intrusions, and that’s what direct primary care looks like. Doctors want to care for patients, patients want to receive care from the physicians. That’s the equation that works.”