Top administrative challenges of 2023: Prior authorizations

Editor's Note: Every year, Medical Economics® asks our physician readers what challenges they are facing in their practices. And every year, we get the same answer as the top challenge: administrative burdens. For our first issue of 2023, we decided to take a stab at fleshing out what some of those administrative burdens are and what physicians can do about them in their practice. We focused on five administrative burdens that our readers commonly tell us are major issues.

The number of prior authorization requests continues to increase — despite promises to the contrary by payers — costing physicians time and money. A Medical Group Management Association (MGMA) poll found that 70% of medical groups indicated that prior authorizations increased in the last year.

Physicians say that their practices continue to struggle with either a lack of response or no response from payers, increased time spent by staff to try to gain approval and a lack of automation in the process.

All these difficulties can lead to delays in patient care. A University of Colorado study found that 93% of physicians reported care delays and that 82% reported cases of treatment abandonment (when the patient does not follow through) because of prior authorization requirements.

“There’s not one standardized way to submit prior authorizations or additional information — maybe clinical information or chart information — to the health plans,” says Anders Gilberg, senior vice president of government affairs for MGMA. “Each health plan thinks they have the best proprietary way to make it really easy.”

But with practices dealing with 20 to 30 payers, that can mean 20 to 30 different websites and passwords.

“The way it works is you have to hire staff to go in there and learn each one of those processes, which is time-consuming and redundant,” says Gilberg. “Ideally, we’re looking for one standard and one way of submitting them, such as pushing a button or maybe having it integrated with an electronic medical record and the clinical record. We could provide the information health plans need but do so in a streamlined way that isn’t just multiplied by 20 and having that staff burden.”

Although that solution doesn’t exist yet and physicians can’t change the prior authorization demands from payers, they can take the following steps to minimize the burden.

Designate a prior authorization champion. Having one person run point on prior authorizations will help that person learn what each payer wants and the best ways to get authorizations approved in a timely manner.

Keep detailed notes for each patient. All it takes is one piece of information to be missing from a patient’s chart for a payer to deny the authorization. Always keep this in mind when documenting a patient’s condition and what tests have been done. If something is abnormal, document it.

Learn what the payers want. Payers will have different requirements before authorizing tests like an MRI. If the payer requires an X-ray first, make a note of that for future reference and complete as many of the requirements as possible before submitting the prior authorization.

Be persistent. Just because a payer denies the first request doesn’t mean you should give up. Some payers have staff with minimal medical backgrounds who review initial requests and may just be looking for key “trigger” words as a reason to reject a claim. An appeal will most likely go to someone with more medical training.

Recruit the patient. Have the patient call the insurance company if necessary. They will be talking to a different department and may either get a different answer or gain clues on what is needed to get the prior authorization approved.

Escalate, escalate, escalate. There is little point in arguing with a payer-employed nurse over a complex medical issue that may be well outside their expertise. Ask for a peer-to-peer review or, in extreme cases, to speak with the medical director or chief medical officer. They still may not have experience in the relevant specialty but will at least have a background to better understand the specific challenge being addressed.