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Why the prior authorization process is still a problem for providers

Will government intervention be the factor that finally pushes the healthcare industry to adopt meaningful prior authorization reform? A bipartisan majority of more than 219 members of the House of Representatives recently co-sponsored H.R. 3107, The Improving Seniors’ Timely Access to Care Act, which “establishes several prohibitions, requirements, and standards relating to prior authorization processes under Medicare Advantage (MA) plans.”

The American Medical Association, a strong supporter of H.R. 3107, has launched the FixPriorAuth campaign to lobby for it. The site highlights statistics from the AMA’s 2019 Prior Authorization Physician Survey and encourages providers and patients to share stories about how the prior authorization process has negatively affected them.  

In Availity’s work with payers and providers, we’ve seen firsthand how inefficiencies in the prior authorization process can delay patient care and drive up overall administrative costs. Here are some of the top workflow problems:           

It takes a long time to determine if a prior authorization is necessary

Many procedures don’t require prior authorization, but provider staff still spend time on hold or wait for a call back from the payer to receive confirmation. With so many payers—each with different types of plans—providers lack a fast, easy way to determine if the process of submitting a prior authorization is even necessary. Consulting provider guides is time-consuming, and providers don’t always trust they have the most up-to-date information from the payer. 

It’s not clear where to submit the prior authorization request

Today, many health plans partner with utilization management vendors to optimize the clinical review process. The challenge for providers is that it’s not always clear when they should submit a prior authorization request directly to the health plan or to the utilization management vendor. Too often, a staff member spends several minutes on a health plan’s website filling out an extensive prior authorization form and submitting it only to find out days later it needed to be submitted somewhere else.

Supporting documentation must be faxed or mailed

Another factor complicating prior authorizations is the requirement to include medical documentation for clinical review. Because the healthcare industry has been slow to adopt automated medical attachments, providers rely on fax and mail to exchange records, which increases the chance that information will be lost, resulting in a delayed response from the payer.   

It’s challenging to keep track of the status

Sticky notes, scratch pads, Excel spreadsheets. These are just some of the low-tech tools provider organizations rely on to manage pending prior authorizations. Front desk personnel must carefully track prior authorizations against patient rosters to ensure they receive an answer before the patient’s visit. Not surprisingly, it’s easy for requests to get lost in the shuffle, potentially delaying a patient’s access to treatment.

There is a lot to do to fix the prior authorizations process, but Availity’s work with payers and their provider networks has started yielding results. Learn how Availity helped one regional health plan streamline its prior authorization process with the Provider Engagement Portal’s Authorization Management solution.