Prior Authorization and You: How Practices Manage the Strain

  

In part two of this three-part series, we explore how individual practices are managing the burden of prior authorizations. (See part one of the series here.)

Prior authorization is just one of the many challenging and complex issues urology practices face each day. In a 2015 survey by Urology Times, more than 89 percent of respondents reported that prior authorization demands are increasing and a recent AUA Snap survey reiterated these concerns. In the AUA's survey, practices reported completing anywhere from five to 300 prior authorizations per week. With each payer having different requirements for prior authorization and no universal form available to cut red tape, what can a practice do? We recently engaged members of the AUA's Practice Manager's Network (PMN) to learn how some offices deal with the burden of prior authorization.

  
                    

Danielle Freedman
Las Vegas, NV

  John C. Lin, MD
Gilbert, AZ
  John O’Connor
Missoula, MT
  Richard Schoor, MD
New York

 

Q: How much time does your practice spend managing prior authorizations and how do you manage them in your practice?

Freedman: Too much time. I have dropped several insurance carriers due to the administrative burdens some of them have placed on us.  It greatly impacts our ability to manage other tasks. This is what it is, though, so I have done what I can to reduce the burden.

The first thing I have done is break up the authorizations into categories. I have assigned my lead medical assistant  to be in charge of doing medication authorizations. She has the basic medical knowledge that a regular administrative employee lacks that helps get the authorizations processed faster. Then I have an authorizations specialist who is required to do patient check out while on hold with insurance companies. Whatever can be done online is encouraged because it provides written documentation and keeps our phone lines free. I have my authorization specialist do authorizations in order of profitability and not by processing time. Our doctor does a lot with erectile dysfunction and benign prostatic hyperplasia, and my authorizations person knows better than to reschedule a Doppler or a UroLift due to “not getting the authorization done in time.” If I have to reschedule a patient for a follow up because their insurance company didn’t get us the authorization in time, it’s not that critical. If I have to reschedule a UroLift when I paid thousands of dollars for the implants and now need to sit on that stock for a while, it is a huge deal. She knows to start with the procedures first and work one week ahead (whenever possible). By working a week ahead, we also don’t end up buying a lot of stock for procedures that aren’t covered. For example, we have a procedure next week that we maybe do once per month. I don’t want to buy the medication for the procedure until I know it is authorized and the reimbursement is adequate for the cost of the medication (this is very important: I am seeing more and more instances where the reimbursement doesn’t even cover the medication at cost.) If the authorization doesn’t go through I don’t need to worry about what to do with a very expensive medication sitting on my shelf. I also look at the patient’s chart and scheduling habits. If I notice that I have a patient with a frequent cancellation history I have my staff call to judge how serious they really are about having this expensive procedure/medication. If they are on the fence about it then we encourage them to cancel prior to me ordering the supplies/meds. There is no point in ordering stuff or getting authorizations for a non-compliant patient. It’s not a perfect system, but that simple phone call has prevented tons of work that would have been wasted. 

Q: What are some of the things that your practice does regularly to help manage the administrative burden of prior authorizations?

Freedman: One of the things I have my staff do about three times per year is update our list of preferred medications for each insurance company. By prescribing certain medications that the doctor already knows are covered and preferred, it cuts down significantly on the authorizations required. For example, several of the insurances unique to Nevada in our practice require patients to try testosterone cypionate before any type of gel, etc. By giving patients this medication up front as first-line therapy, it cuts down on lots of angry phone calls from patients and cuts down on the workload for the staff. The same can be said for oxybutynin as a first-line therapy for overactive bladder for lots of insurances. While the system is not perfect, it certainly has prevented a lot of extra work by having the doctor consult a quick list in advance. I leave copies of the lists at every work station for him to reference when he comes out of a room. This process also helps future prior authorizations from being denied due to step therapy, because the documentation that the patient tried and failed the first line of therapy is usually always available. This helps patients that have tried and failed a generic, etc., and want to proceed with a second drug.

Schoor: According to my staff, the easiest way to manage this is to ask insurance companies to fax pre-authorization forms for physicians to sign later. This works for medications, but for radiology authorizations, we just have to wait on the (speaker) phone.

Dr. Lin: If your provider knows that the medication will not be covered or is poorly covered (e.g., erectile dysfunction medicines), informing the patient to expect a large out-of-pocket expense and that you will not be performing any pre-authorizations for such medications usually helps.  You can also give the patients discount cards accompanying the drug sample or advise them to go directly to the medication manufacturer's website for coupons and other financial assistance.

Q: What role does an EMR system play in managing prior authorizations?

Dr. Lin: Your electronic health record (EHR) vendor should automatically be updating payer formulary lists weekly. While choosing a medication in the EHR, the preferred formulary status and tier should be listed next to the medication. This allows for not only choosing the best medication, but the most cost effective medication for the patient, while avoiding the need for pre-authorizations. Also, your EHR may have an eAuth feature, allowing electronic submission of prior authorization from your EHR and return of coverage confirmation within minutes.

Schoor: The EHR is essential, and allows ready access to clinical and ICD-10s as needed.

Freedman: Our EMR is not where it needs to be with helping with authorizations. First off, our EHR never updates the formularies in a timely manner. Things change every quarter and we seldom get an update in time before we generate a phone call from a pharmacy letting us know that something is no longer covered. Our EMR only notifies us when a medication is not on formulary. It has no ability to tell the doctor that the patient has already tried and failed a step therapy (in other words, no pharmacy interfaces available to see what patient has been given by other doctors). We also have no way to submit information from our EHR other than faxing office notes to the insurance company to get prior authorization. If we could send the information to an insurance company for a specific procedure for an authorization and not have to fill out additional forms, etc, it would be ideal. This solution I am sure is coming in the future but not for a long time. We rarely use our “formulary” feature for our EHR. It just isn’t useful enough. 

Q: Are there third-party tools available to help navigate the prior authorization process?

O’Connor: Covermymeds is free (industry funded). You can create a profile and link in your providers and your users (we have profiles for all our LPNs & MAs). They have made major improvements in the past year to make the process easier. I stopped by their booth at MGMA last year and made some suggestions...to my delight they are working on two of them; having the ability to upload and save patient information for future use and expanding to imaging/procedure prior authorizations. This really is a time saver for our staff. 

Schoor: We use Phreesia for check-ins, eligibility, copay and deductible amounts. 

Freedman: There are a lot of third party tools that help in the prior authorization process, but these are sometimes more time consuming then just doing the authorizations ourselves online. By the time you give a lot of these companies the patient information, clinic notes and fill out their forms you might as well just do all that and submit the authorization. The intention is good, but it’s not always the best time-saving option to let a third party do it. 

Q: Do you have any other tips for practices struggling with prior authorizations?

Freedman: One thing I do require is for the place we send our radiology to to get their own auths. We send over the order with the clinic notes and they do their own authorizations. The same goes for hospitals when they want us to authorize the devices they stock for the procedures the doctor performs. I refuse (unless insurance mandates it) to allow my staff to spend the time to do somebody else’s work for them.

It’s also important to note that prior authorizations require very good documentation in the doctor’s clinic note. Just as we like efficiency, insurance companies like efficiency. I’ve noticed that insurers don’t always read every page of records I send. If the doctor could put a note in the chart that says,  “patient has tried and failed medications xyz and his or her symptoms are worsening and now require procedure xyx or medication xyz as a next step therapy…” it often takes less time for the insurance company to approve and removes any ambiguity. They can’t argue with good documentation!

What is the AUA doing to help urologists ease this burden? Find out in part three of this series



#CodingandBilling #PaymentandCoverageIssues #2016
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