Prior Authorizations: 5 Ways to Beat the Hurdles

Leigh Page


January 08, 2019

In This Article

Make the Move to Electronic Authorization Requests

According to the 2018 CoverMyMeds report, 96% of patients are in plans that are either connected to ePA systems or were committed to doing so in 2018, up from 68% in 2015. The report also found that 79% of EHRs had integrated ePA into their systems or had committed to doing so in 2018, compared with 54% in 2015.

Not all ePAs are equal. Depending on the brand, ePAs can determine whether a prior authorization is required for the drug, provide the plan's rules, submit the request in some cases, and check for approval, but only a very few ePAs automate submission of documents, according to executives at Availity, a claims clearinghouse and provider of revenue cycle solutions provider.[6]

A few states require payers to provide ePA for prescriptions; these include Texas, Minnesota, Pennsylvania, Indiana, California, and Ohio, according to the CoverMyMeds report. In contrast, the AMA's state-by-state report of prior authorization legislation lists 17 states requiring some form of ePA, but this seems to involve a looser definition of ePAs.[7]

Even Medicare will start requiring ePA for Part D drugs starting January 1, 2021.[8] Whereas regular Medicare only uses prior authorizations for medical equipment and mobility devices, Medicare Advantage plans use them for many types of physicians' orders.[9]

Although ePAs have made great strides for simple drug prior authorizations, the approach still typically can't be used to send documentation, which is needed for requesting specialized drugs, appealing authorization decisions, and requesting prior authorization for procedures.

Sending attachments requires a different electronic standard than the ePA for drugs. Congress authorized the Centers for Medicare & Medicaid Services (CMS) to implement this standard 23 years ago, but CMS has not gotten around to doing so yet, according to the AMA.[10]

To make up for the inability to receive documentation via ePAs, many payers have opened web-based portals that accept documents. Sending documents through portals is less time-consuming than sending them by fax, Boudreaux says.

But don't throw out your fax machine yet. It's sometimes still the only way to send documentation.

4. Be Persistent When Appealing Denials

The key to successful prior authorizations is persistence, all the way to filing appeals.

After sending in a request, staff should regularly follow up with the payer to make sure the request was received and is being processed. The prior authorization process is still primarily manual and thus error-prone. This work can often be done via ePAs.

Even when requests are denied, that's not the end of it. Many requests that were initially shot down were finally granted on appeal. According to one account, 90% of insurance appeals are eventually approved.[11]

Many requests that were initially shot down were finally granted on appeal.

Finding errors in the payer's approval process can overturn a denial. Errors can be rife, especially when the review process is complicated. The 2018 CoverMyMeds report found that 30%-50% of prior authorization denials for specialty drugs involved administrative error.

Also, nonphysicians typically review requests. They may reject your application out of hand without appreciating the nuances of your medical decision. However, payers refute the allegation that reviewers get bonuses for denying care.[12]

Appeals typically involve talking to a physician who is a medical director at the insurer. But these physicians may not be in your specialty, and they may never examine the documentation you present. In February 2018, it was revealed that a former medical director for Aetna in California never looked at patients' records when deciding whether to approve or deny care.[13]


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