The Downstream Effects of Prior Authorization
|Prior authorization is the requirement that healthcare providers submit a request justifying insurance coverage. It’s meant to ensure that the insurance companies and providers agree on what is needed for care to occur. However in practice, this isn’t the only thing prior authorization causes.
Most notably, there is a significant delay in care seen when prior authorization is needed. It takes time to collect files, call insurance companies, and justify the request for coverage. This is time which is not being spent actually treating the patient. Even worse is when the request is denied and an appeal has to be claimed.
Appeals are another level which nearly half of physicians don’t have the time or resources to pursue. 35% of providers will hire staff to submit prior authorization requests for them, but most cannot afford to pay. In these cases, the patient may never be able to get the care they need. This is why prior authorization has led to life-threatening events for 19% of over 1,000 providers surveyed.
Unfortunately, as long as the system continues to operate like this, not much can be done. One avenue to at least ease the burden on providers is utilizing automation technologies. Services which can look up patient files, call insurance companies, and submit requests, all very quickly and efficiently. These services aren’t perfect but they equalize the burden it takes to have staff do this job. Instead of heavy human investment, automation only requires human interaction when things go wrong.
Outside of this prior authorization still represents a challenge for patients and providers alike. Currently 70% of prior authorization processes rely on manual labor. Now, there are prior authorization process automation services that can help to reduce this number and the strain on the system, but not much else. The root of prior authorization isn’t inherently corrupt, but until it’s streamlined these negative effects aren’t going anywhere.
Source: Orbit Healthcare