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Prior Authorization Best Practices

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Prior authorization is also referred to as prior approval, precertification, or preauthorization. This is a health plan cost-control process that necessitates certain medications, procedures, and tests prescribed by healthcare physicians to be evaluated before authorization. This plan is utilized by health insurance agencies to ensure patients receive only necessary medical care. 

Today, health insurers use it to lower their costs and improve care quality for their members. However, the process of obtaining prior approval for services creates a significant burden for providers. 

According to the Medical Group Management Association (MGMA) survey, 86% of the healthcare providers said that prior authorization requirements increased in the past year. And another 82% of healthcare providers in a new MGMA study identified the pre-approval process as their top regulatory burden in 2018. 

Overcoming the Burden of Prior Authorizations

Providers today can overcome the burden of dealing with prior authorizations by using staff to focus on prior approvals, proactively checking requirements, and most importantly, automating the entire process. 

Automating Prior Authorizations 

For years, prior authorization automation has lagged compared to other claim management processes and that has continued to impact the performance of providers as well as that of health insurers. In fact, according to the Council for Affordable Quality Healthcare, Inc. (CAQH) recent index, the adoption of fully electronic prior authorization transactions decreased by 11% between 2016 and 2017. At the same time, the volume of prior authorization transactions went up from 32 million to 37 million. 

The 2017 CAQH Index further discloses that manual prior authorizations cost providers $5.75 each and require between 14–20 minutes of staff time each. A 2016 study also reveals that for every hour physicians spend with patients, they spend about two extra hours on the paperwork. 

If these figures are anything to go by, switching to automated prior authorization saves you time, money, streamlines the entire process, and prevents errors. This is very true especially for high ticket medications and procedures such as surgeries that can be done safely in the outpatient setting, durable medical equipment (DME), MRIs, and specialty drugs. 

American Medical Association (AMA) believes the entire volume of drugs and medical services requiring prior approval should be greatly reduced. They further advise providers to consider implementing electronic prior authorization (ePA) technologies to streamline the prescribing process. 

Electronic Prior Authorization automates the process for medications through integration into an electronic prescribing workflow and the provider’s EHR system. It doesn’t involve downloading forms from payer websites, re-entering data into proprietary health plan portals, and using a fax machine. 

Providers need to discuss ePA technology with their EHR IT companies to determine if they offer electronic prior approval solutions. Thankfully, some like NewCrop already have ePA solutions with EHR capabilities and in the process to partner with SureScripts to offer prior authorization services.  

Best Practices for Prescribing Physicians 

Below is a list of prior authorization best practices for making the entire process of prior authorizations a little easier.

Have a Designated Person 

Having a specific person who understands the entire practice can free you the valuable time you spend catching up with the latest changes affecting e-Prescribing. Keep in mind there are no standard rules and processes. They vary from one insurance provider to the next, and as such you need to be up to date with all when dealing with multiple insurance companies. 

By designating a person (depending on how huge your practice is, a small team may be necessary too) who understands the practice to take care of this, you won’t spend a lot of time trying to figure out what is new when submitting a prior approval. Plus, this will help you avoid common mistakes that tend to slow down this process. 

Know Your Triggers 

Each practice has its set of unique procedures and medications that are likely to trigger prior approval requirements. Your practice is no exception. As such, look around and take note of the procedures and drugs you frequently use that may require pre-authorization and have options ready. 

If you notice a certain drug is causing issues, try to see if there is an adequate substitute that will not require prior approval—for example, a generic drug. With a list of drug-ready options, you may be able to avoid the challenges of prior authorization altogether. 

Customize Your EHR

Modern EHR can be customized to send notifications when a procedure or drug is likely to require prior authorization. Some can even be configured to recommend alternatives. If you have or represent such a system, configure it to generate alerts and if possible, a list of details the insurance will need. That way, you and your staff will save a lot of time and cut costs when moving through the process. 

Keep Patients in the Loop 

Prior authorizations are not just stressful for you, they are also stressful to your patients, and most of the time they won’t have an idea of what is happening unless you keep them in the loop. To avoid scenarios where they blame you for delays, and to show you value their health, try your best to keep them up to date. For example, leave them a note via their portal or make calls. 

Go Electronic

Going electronic is the new norm and many prescribing physicians are loving it. It is saving them more time. However, there is an issue that seems to be slowing the rate at which doctors are switching—most portals for submitting prior authorization are outside the EHR. Luckily, this is not a big issue as there are companies like NewCrop offering EHR e-Prescribing integration and e-Prescribe without EHR. Whichever option you settle for, ensure you are well-trained to make the most efficient use of it. 

Prior authorizations can turn out to be problematic for your practice especially when patients have to wait longer to get their medication. However, by implementing the above prior authorization practices, the entire process can be a bit easier. 

Automating prior authorization makes the process more friendly and with players like NewCrop, you do not need to worry about getting a modern solution. Send electronic prescriptions to your pharmacy of choice easily today with NewCrop. How? Schedule a demo today.