The paperwork burden of prior authorization keeps climbing, and for some ASCs, the only way through is to treat it like a daily fight.
Elisa Auguste, administrator at East Setauket, N.Y.-based Precision Care Surgery Center and vice president of the New York State Association of ASCs, joined Becker’s to discuss the playbook her team uses to push back, keep cases moving and protect patient care when payers delay or deny payments.
The average medical practice completed 43 prior authorizations per physician, per week, in 2024, according to an AMA survey. Physicians and staff reported spending about 12 hours per week completing such paperwork.
The number of prior authorizations in Medicare Advantage rose each year from 2021 to 2023, according to data analyzed by KFF. In 2023, MA insurers denied 3.2 million, or 6.4%, of prior authorization requests. Though the volume of prior authorizations increased from 2022 to 2023, the number of denials declined.
Here is Ms. Auguste’s five-pronged approach:
1. Enlist patients early
First, the ASC works with patients to contact their insurance companies directly. Ms. Auguste said patients can help push the request forward, especially when they reiterate the urgency and clinical need.
2. Over-document and escalate
The team also “pushes documentation,” assembling medical records and ensuring providers call payers when needed.
“We’re actively fighting the insurance company regularly and escalating every single time,” Ms. Auguste said.
3. Proceed with cases when patients can’t wait
In some situations, when Ms. Auguste believes authorization is unlikely but the patient needs surgery, the ASC proceeds anyway to avoid delaying care.
“We’ve done cases where we were waiting on authorization, and we just went ahead so the patient wasn’t in pain and didn’t have issues, and then after the fact, it gets denied,” she said.
That can mean the center ends up absorbing the cost.
“So now we’re doing it for free. And like I said, patient care is always the utmost priority. We will do cases for free where we don’t get paid. The problem is it’s not a sustainable system.”
Ms. Auguste said Precision Care Surgery Center can sometimes withstand those losses because of its payer mix.
“We have a decent payer mix, so we’re able to perform other commercial cases where you make a little bit extra, and that helps cover where you lose in other cases,” she said. “We look at it as a whole: some cases you lose on, some cases you make on, and it balances out.”
4. Refuse to cherry-pick patients, but acknowledge the risks
Ms. Auguste said the ASC treats a wide range of patients and doesn’t limit cases to only higher-margin payers.
“We do everything — Medicaid, HMO cases, Medicare HMO, straight Medicare and commercial. We never want to be the facility that only takes cases we’re going to make money on,” she said.
But she also noted that strategy is harder for ASCs that don’t have the same geographic advantage or commercial volume.
“For someone who doesn’t have the advantage of a better location and payer mix, you really have to rely on patients and providers working together and going back and forth with insurance companies,” she said.
5. Use contract negotiations as leverage
Lastly, Ms. Auguste said contract negotiations are part of the prior authorization strategy, including the willingness to walk away from a payer if issues persist. If a payer forces those patients back to a hospital setting, the cost is typically higher, giving the ASC leverage in negotiations.
