Prior authorization eats up a significant amount of time and money from a practice, in addition to sometimes delaying patient care. One option to alleviate this burden is to outsource the prior authorization process to a third-party company. Many full-service practice management companies take on the entire prior authorization process while some companies specialize in a single area, such as medications. (Image courtesy of Getty Images.)
Every practice has felt the strain of prior authorizations, from filing claims and fielding denials to waiting for approvals and negotiating with payers. According to the American Medical Association’s 2021 physician survey, 93 percent of physicians reported care delays for their patients’ treatments and 82 percent reported that prior authorization sometimes leads the patient to abandon their recommended treatment. These delays and complexities can have serious consequences: physicians also reported PA leading to serious adverse events, hospitalization, life-threatening events or permanent impairment, disability and congenital anomalies/birth defects or death.1
Both the AMA and the American Academy of Ophthalmology are working toward prior authorization reform in Medicare Advantage programs.2-3 In the meantime, here are a few PA services and tools that may help to lift some of the burden from you and your practice.
What’s Right for Your Practice?
When each insurance company has its own definition of what’s medically necessary or what counts toward step therapy, ensuring proper care for your patients can be a challenge. In some practices, it makes the most sense to assign a specific staff member or several to handle PAs. Many EHRs already have electronic PA filing systems, which can make this process simpler.
Other practices may want to look into outside help from PA tools or companies that specialize in PA. Many third-party outsourcing companies manage the PA process—reconciling different companies’ requirements, forms, decisions; work with physicians and patients to obtain necessary information; and make appeals against denials.
As with any potential outsourced vendor, be sure to vet the company for security, transparency in reporting and good communication. Also be sure to find out what types of PA services they offer. Some are full-service and some are prescriptions-only, for example.
Prior Authorization Services
In many instances, outsourcing to companies that specialize in prior authorization can lead to faster approvals, more revenue and fewer clinic hours devoted to administrative work.
Here are a few companies that offer prior authorization services:
• Health Prime’s Prime Authorization. This practice optimization company virtually obtains and processes PAs for the practice, with supplied documentation. Health Prime says its services reduce denials, save the practice time and money, minimize data errors and improve patient care. The company says it’s HIPAA compliant and keeps up to date with changing government regulations to ensure compliance. For information, visit http://www.hpiinc.com.
• AthenaOne Authorization Management. Practice management company Athenahealth’s PA specialists handle the PA process after the physician submits the order into the Athenahealth EHR. The company’s Authorization Rules Engine checks all submitted orders against up-to-date payer requirements to determine whether PA is needed, and then begins the process when appropriate. The company says it provides clinical documentation submission, payer follow-up, end-to-end visibility and real-time processing. There’s also a same- or next-day authorization option, where same-day authorizations are initiated within two hours of receipt. The company says 94 percent of urgent authorizations are completed within 48 hours. For information, visit http://www.athenahealth.com/solutions/authorization-management.
• Infinx. Infinx uses artificial intelligence and automation technology to speed up prior authorizations. The cloud-based software facilitates electronic requests. More complex requests and exceptions are handled by a team of specialists. The company provides real-time communication with automated follow-up bots that check requests under review for status change updates. Infinx says it provides complete coverage of PA requests with 98-percent accuracy and 99.5-percent adherence to turnaround times. Visit http://www.infinx.com/prior-authorization for more information.
Medication Prior Authorization
Timely medication prior authorization processing is an important aspect that can affect patient compliance.
Here are some companies that specialize in medication prior authorization:
• CoverMyMeds. This free online platform (part of McKesson) for physicians and pharmacists aids claims submissions using questions and prompts for filling out electronic PAs and guides practices and patients through automatic PA renewal. The tool is compliant with all ePA legislation and uses encrypted SSL technology to ensure data privacy. The platform is integrated with more than 500 EHRs and 72 percent of U.S. prescription insurance plans (including Medicaid and Medicare Part D). It’s accessible from anywhere with an internet connection. Visit http://www.covermymeds.com for more information.
• SureScripts. SureScripts helps speed up the PA prescription process with streamlined ePA tools and electronic requests that the company says obviates the need for faxes, paper forms and phone calls. Documentation can be submitted through the portal. SureScripts narrows down only relevant patient-specific questions, pre-populates fields from the EHR, performs data validation and initiates benefit plan renewals. SureScripts is free and doesn’t require an EHR (though it integrates with many); it also doesn’t store or maintain information of portal transactions, though this means users need to retain their own copies. Visit http://www.surescripts.com for more information.
• Medly. Medly is a full-service pharmacy that manages PAs, including insurance validation and claim filing, applying financial assistance, coordinating medication delivery with the patient, and following-up with the patient to maintain adherence, address side effects, answer questions and process refills.
In the February issue of Review, Ramya N. Swamy, MD, MPH, of Baltimore, noted that outsourcing medication prior authorization to Medly made the process easier on her end since the company took care of everything once they received the online prescription. For more information, visit http://www.medly.com.
1. The 2021 AMA prior authorization (PA) physician survey. American Medical Association. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf. Accessed February 7, 2023.
2. Fixing prior authorization. American Medical Association. https://www.ama-assn.org/amaone/ama-recovery-plan-america-s-physicians-fixing-prior-authorization. Accessed February 15, 2023.
3. Prior authorization. American Academy of Ophthalmology. https://www.aao.org/advocacy/prior-authorization. Accessed February 15, 2023.