Physicians are spending more time than ever on prior authorizations for treatments and procedures, which many say has a negative impact on patient care.
Here's what six physicians want to see in prior authorization reform.
Editor's note: Responses have been lightly edited for clarity and length.
Klaud Miller, MD. Orthopedic Surgeon and Medical Director of Windy City Orthopedics and Sports Medicine (Chicago): What do physicians want on preauthorization? We want it banned! Preauthorization does absolutely nothing except try to save the insurance companies money after we finally give up. It does nothing for the patient or the doctor. It causes physicians lost time and money and only delays appropriate treatment.
Andy Anderson, MD. Chief Medical and Quality Officer of RWJBarnabas Health (West Orange, N.J.): Physicians would like the prior authorization process to be simpler and faster, so that patients can receive medically indicated tests and treatments in a more timely manner. Unnecessary delays in tests and treatments create stress for patients, families and physicians who are waiting for needed approvals. The practice of medicine is individualized and personalized and physicians need to practice efficiently at the top of their license. Procedures, delayed or denied, from poor communication or lack of transparency in the process, frequently cause increased emergency room and hospital utilization and poor patient outcomes. Therefore, physicians, hospitals and health systems expect that the updated CMS rule for prior authorization, published earlier this year, is adopted by all payers, including commercial plans. This will improve the process and build more transparency and accountability into the workflow.
Seref Bornovali, MD. Hospitalist and Post-Acute Medical Director of Velocity Clinical Research (Cincinnati): Main concern regarding the prior authorization process is that it is being used as an excuse for non-payment instead of a medical-review process. A fair prior authorization process should be:
1. Objective: Criteria should be based on well-established medical evidence.
2. Timely: Patients should not have to wait more than [one or two] days.
3. Easy: The process to request prior authorization should be easy and simple. Currently it is very time consuming.
4. Transparent: If denied, the reasons for denial should be clearly defined. Appeal [and] reconsideration avenues should be clear and simple as well.
5. Compensated: Prior authorization is part of patient care. The physician or staff time spent for prior authorization should be billable and paid for properly by the insurance companies.
Rory Murphy, MD. Neurosurgeon and Associate Professor of Neurosurgery at Barrow Neurological Institute (Phoenix): [We want] the health of our patients [to be] prioritized. Too [much] added uncertainty and distress is added to a patient's preoperative preparations. Surgeries are often only approved sometimes hours before the procedure despite all evidence being submitted to the insurance company weeks and sometimes months in advance.
Nusrat Chaudhry, MD. Clinical Operations Physician of Contra Costa Health Plan (Martinez, Calif.): Prior authorization should be integrated into electronic medical records, and codes should be automatically filled rather than physicians searching and being unclear about what is covered or not. Increase transparency and provide detailed reasons for denial rather than just writing about health plan policy. Every health plan policy should be open to everyone and accessible, as transparency is imperative for both patients and physicians. If patients can read all my chart notes and data through my chart, why are health plans not open to providing all their policies on the web? Only a few significant health plans have open-access policies. It is difficult to find codes and matching diagnoses for covered and noncovered benefits, which delays patient care. [Authorization] should be valid for a long time for chronic illnesses as reviewers change; and sometimes, there is no standardization among health plan reviewers.
Frederick Hoenke, MD. Family Medicine Physician and Geriatrician of Lifepoint Health (Marquette, Mich.): Unfortunately, it is pretty obvious. The private insurers have been functionally unchecked in this process and by numerous reports, with a process of high denials that no doubt they have statistically analyzed to make them a certain level of profit. If you think about it, it is a classic fox watching the hen house — how can anyone believe that the business profiting from not paying out to cover diagnostics should be able to deny the physician with all of the clinical training [who is] seeing the patient? … The entire premise for the process is absurd.
It is terribly costly in my practice with staff's time and my time spent justifying to a non-clinical person of lesser training, at best, why I have ordered diagnostics or medications. It is a major frustration. Perhaps we ought to make it much easier for patients to sue — and win — these insurers for delays in diagnosis and treatment. The entire process is fundamentally flawed as above. Perhaps we should require the insurers to hire additional staff with more advanced degrees and experience to research and provide concrete reasons for any denials. If they felt the same pain that we do for cost and time, it might improve the situation.