Prior Authorizations: 5 Ways to Beat the Hurdles

Leigh Page


January 08, 2019

In This Article

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But there are ways to make the process more efficient. Processors have large volumes, so they can be reasonably assured about which processes need prior authorization. They also assign specialists to certain payers or procedures. Even practices with much smaller volumes can copy these techniques.

Another tip: Even though plans don't update their prior authorization lists, they often announce policy changes in newsletters, bulletins, and blogs on their websites, the AMA advises. It pays off for staff to track down these sources.

2. Provide Proper Documentation to Increase Success

Determining what drugs or services require prior authorization is just half the battle. You have to provide the correct documentation before you can be approved. The documentation can be quite complicated, and again, the requirements vary from payer to payer and are often unspecified.

"A certain payer may require information on whether patients took anti-inflammatories before it will approve a surgery, and another may require information on comorbidities to qualify for in-lab sleep studies," Boudreaux says. "Requiring this information is not mentioned in the denial message. The only way to find out is to call the payer."

Prescription prior authorizations are often light on documentation. Basically, only an application form is needed. There are exceptions. Expensive specialty drugs, such as biologics or cancer treatments, can require a great deal of documentation.

On the other hand, medical services quite frequently require documentation, even for relatively simple treatments, Bollinger says. For example, kyphoplasty, a minimally invasive procedure to treat compression fractures, requires documentation, he says.

The rules for documentation can be very complicated, and it can take a while to gather appropriate information. For example, in prior authorizations for genetic testing, "the case for medical necessity has to be done flawlessly," Bollinger says. "Any missing information, and the request will fail."

On the payer end, requests involving documentation often have longer approval times. A patient may wait 3-6 weeks for treatment without a specialty solution, according to the 2018 CoverMyMeds report.[4]

How do you find out about documentation requirements? Sometimes payers spell out documentation needs, but more frequently, you have to sniff them out by identifying trends and investigating, Boudreaux says.

For example, Azalea worked with a practice that was consistently getting a certain procedure denied by one payer and couldn't understand why. "We found that the payer wants documentation that patients were treated with a conservative option, NSAIDs [nonsteroidal anti-inflammatory drugs]."

You can get insights into documentation by reaching out to staff at other practices that deal with the same issues. Once you have the information, put it in a centralized database that everyone in the practice can share. This could be an electronic dashboard in your electronic health record (EHR) system, Boudreaux says.

Successful documentation also requires frequent communication between staff and physicians. Staff should inform physicians on what documentation needs to be in the chart.

"Consistently document data required for prior authorization in the medical record," the AMA advises. "This can help you avoid delays in patient therapy, prevent potential follow-ups with patients for additional information, and minimize time spent on authorization."[5]

3. Use Your EHR to Implement Authorizations

One way to reduce your prior authorization workload is to use electronic prior authorization (ePA) software, which can reduce the turnaround time for many prescription ePAs to a matter of minutes. In this way, a prescription can be cleared before the patient's appointment ends, says Luke Forster-Broten, manager of product innovation at Surescripts, an ePA vendor.

For an ePA to work, payers have to connect to it and be able to transfer data, and EHR vendors have to incorporate these systems into their EHRs. Both groups have made enormous strides to this end in recent years.


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