Providers and hospitals have long said the prior authorization process is problematic and cumbersome for them, as many health plans have different requirements and submission guidelines.
Prior authorizations are a process in which a provider, on behalf of a patient, requests approval from the patient's insurer to ensure the treatment or service will be covered. This process was designed to ensure patients are receiving care in the right setting based on efficacy and safety. Payers argue prior authorizations help lower costs for beneficiaries, while providers say they can lead to care delays and contribute to staff burnout.
This left us wondering: What would revenue cycle leaders at hospitals do to meaningfully improve the process if they could?
Here, four revenue cycle leaders share what they believe would improve the process.
Editor's note: Responses were lightly edited for length and clarity.
Julie Franer. Administrative Director of Revenue Cycle at Sierra View Medical Center (Porterville, Calif.): I think what could help is a "uniformity" among all health plans on what services require an authorization so it takes the guesswork out of who and what plan requires one. I also think having a universal evidence-based medical necessity criteria to support the need would help to streamline the process across all health plans. If all plans required the same documentation, it would help streamline the process.
Barbara Hayes. Revenue Cycle Manager at RestorixHealth (Tarrytown, N.Y.): I'd say two major things:
1. Timely and accurate prior authorization program review by the insurance providers. This can help identify procedures that no longer justify prior authorization and identify new services and procedures that may need prior authorization.
2. Transparency in authorization requirements and ease of communication. Some insurance policies and/or communication are confusing regarding what procedures need authorization depending on the place of service, i.e., clinic, outpatient facility or ASC locations.
Maria Kamenos. Vice President of Patient Access Services at Spectrum Health (Grand Rapids, Mich.): There are many different ways in which the prior authorization process could be made better, easier and more efficient for payers and providers, and we think there are three major changes that would be good places to start:
1. Payers and their [third-party administrators] should be required to make available in a standardized, machine-readable format, up-to-date medical policies including what services (CPT, J-codes, etc.) require an authorization, whether or not the service is a covered benefit or not, and what the auth requirements are.
2. Submission and responses for authorization are made standard across all payers, are electronic and automated — eliminate faxing and cumbersome, manual calls and processing. Where there still may have to be calls, such as peer-to-peer reviews, give providers the ability to call when it's convenient for them not at the convenience of the payer.
3. Payers must respond to elective/routine authorization requests within 48 business hours and for urgent requests, within 24 business hours. Timely responses lead to timely care for the patient.
Lisa Schillaci. Vice President of Revenue Cycle Operations at Houston Methodist: Prior authorization is generally a completely manual process with automation quickly coming to the rescue for certain services. Automation is only part of the solution. Payers should consider reducing or eliminating the need for prior authorization on services with a high first-pass approval rate. For more complicated authorizations, I'd like to see the payers and providers co-create minimum documentation sets that can be easily accessed and shared. And lastly, the payers should share some risk when they fail to respond to providers in a timely fashion. Patient care should not be delayed or denied due to an overly bureaucratic process. I understand the need for prior authorizations, and as an industry, we have to find a better way.