For many physician practices -- especially those working with health maintenance organizations (HMOs) -- obtaining pre-authorization to perform certain treatments or procedures is a necessary evil: Physicians must request pre-authorizations accurately and in a timely fashion or they won't get paid.
Unfortunately, pre-authorization rules for some payers are quite complex. The level of detail needed for specific requests compounded by the number of items that require pre-authorization can result in an effort that is both time consuming and difficult to manage for physicians. In addition, the number of exceptions to pre-authorization rules can be frustrating particularly if the distinction between procedures that require prior approval and those that do not is ambiguous.
Frustration Leads to Abrasion
Physicians can lose patience with a payer's pre-authorization process if they don't clearly understand which procedures require approval, how that should be sought and when they will receive an answer to the request. This frustration can lead to physician abrasion--the concept that a payer's relationship with a physician may be negatively influenced by certain activities or circumstances, such as a complex and lengthy pre-authorization process.
If left unchecked, physician abrasion can be detrimental to a health plan. In some cases, physicians may unknowingly communicate their frustration to patients, which can damage the reputation of the health plan. Consider the physician who has to obtain a pre-authorization to perform a specific surgical procedure. The physician could express frustration to the patient about the difficulty in gaining pre-authorization, causing the patient to worry that the health plan won't pay for the procedure. The physician may even inadvertently convey that the health plan is not concerned about the patient's health.
Physician abrasion can also lead to increased workload for the health plan. For example, to ensure they request the appropriate pre-authorizations, some practices may choose to request them for nearly every procedure or treatment they provide. This generates a multitude of unnecessary requests, which results in a deluge of work for health plans.
Avoiding Physician Abrasion
There are ways to prevent physician abrasion related to pre-authorization processes. Following are several recommendations to consider:
• Standardize and simplify. The easier a health plan makes its pre-authorization process, the better things will be for all concerned. Physicians will be able to smoothly navigate the process and request appropriate pre-authorizations in a timely manner. Health plans will be able to grant permission faster and get patients the care they need more efficiently.
Health plans should take a look at their processes and make sure they are clear, concise and non-duplicative. One way to get a sense of how challenging your processes are is to ask one of your own staff members to "walk through" the pre-authorization process--pretending to be unfamiliar with it. If the staff member has difficulties, then you know your process is too complex.
• Provide a checklist. Health plans may want to create a checklist that easily highlights frequently performed procedures and treatments that require prior approval. The checklist should also clearly note any exceptions. Sorting the checklist by specialty helps a practitioner quickly locate pre-authorizations that relate to his or her practice.
It's important to keep any checklists up-to-date. Health plans may want to assign a staff member to regularly update the checklists with applicable requirements and exceptions.
• Create multiple submission opportunities. Providing several venues to submit a pre-authorization request can further improve the process for practices. For example, some practices may feel more comfortable talking to a "live" person to request a pre-authorization, so a telephone-based process is beneficial. Other practices may choose to submit requests electronically, so having an online submission form would be appropriate. In the future, working with an electronic health record (EHR) vendor to incorporate pre-authorization request mechanisms into the EHR technology could further streamline the process for all parties.
• Standardize response times. Physicians will be more satisfied with the pre-authorization process if they know what to expect. Health plans should consider establishing timeframes for responding to pre-authorization requests and consistently meeting those timeframes. Turnaround should be relatively quick to ensure patients receive timely and appropriate care.
For those authorizations requiring a more detailed review, health plans should let the physician know upfront of the need for more time, the reasons behind the need, and a timeframe in which the physician can expect to receive further communication from the health plan. This will allow the physician to plan accordingly and communicate the information to patients.
While physicians may never enjoy the pre-authorization process, health plans can make it as painless as possible. Using the above-mentioned tips, you can ensure your approach supports positive physician interactions. This will not only preserve your relationship with physicians but also enhance your reputation among patients.
Rolland is the SVP, Product Development for Medicare Advantage at Outcomes Health Information Solutions.