Prior authorization (PA) is time-consuming and fraught with administrative and financial burdens for physicians and their staff, typically requiring extensive communication and follow-up for disruption due to prior authorization. A recent American Medical Association survey revealed that physicians and their staff spend an average of 13 hours each week completing PA requests. On an annual basis, that is nearly 853 hours dedicated to prior-authorization tasks. The time burden is so great that about one-third of physicians have staff members who work exclusively on prior-authorization duties.
Even more frustrating is the fact that 93% of physicians say that PA delays patients’ access to necessary medical care, and 82% of physicians report that PA processes also result in abandonment of treatment. Other studies have linked prior authorization to treatment delays, emotional distress, and worsening symptoms. Also, a survey conducted by the AMA reported that 88% of providers classify the burden of prior authorizations as high or extremely high. Besides the significant investment of time and energy, Prior Auth is also extremely expensive for a practice to undertake.
Inevitably, groups such as the American Medical Association have raised concerns about the cost burdens of PA. Estimates of the cost burden to physician practices vary considerably, in 2010 it was estimated to be from $80,000 annually per physician to between $2,200 and $3,400 annually per physician. It should come as no surprise that The Centers for Medicare and Medicaid Services (CMS) proposed a new rule to advance interoperability and improve the prior authorization process. The intent behind CMS’s move is to foster transparency, reduce physician burden, and speed- up patient access to quality care.
However, the provisions for the CMS rule will not go into effect until 2026. Meanwhile, it is up to practices and their partners to manage prior authorization the best that they can. This begins with understanding what disruption due to prior authorization is, along with why it is necessary.
Prior authorization is a utilization management process primarily used by healthcare payers. This process requires that certain treatments or prescriptions which are prescribed by clinicians to be evaluated for medical necessity and cost-of-care ramifications before they are approved and reimbursed.
This process was formulated to ensure that patients receive safe and effective treatments. Payers = can see how a covered patient utilizes their coverage and what treatments they may have previously received, thus helping prevent duplicate and unnecessary treatments for disruption due to prior authorization.
Outsourcing your prior authorization processes can help to reduce administrative burden and enable you to improve your bottom line. At EMPClaims we specialize in Revenue Cycle Management services including prior authorizations and help to simplify complex medical billing operations. Want to learn more about disruption due to prior authorization?
Visit our website for more ways to master the prior authorization process.