What private practice physicians need to know about prior authorization

Prior authorization is a big part of private practice physicians' jobs, but it's among the least popular parts of healthcare for providers of all kinds. The good news: There are signs that reform is gaining momentum.

A 2021 AMA survey found 91 percent of physicians said prior authorization can lead to negative clinical outcomes, while 82 percent said it can lead to patients abandoning a course of treatment. Some physicians have seen the ugly side of it firsthand: 34 percent reported that prior authorization has led to a serious adverse event for a patient in their care.

Making matters worse, the workload from prior authorizations fills nearly two full business days per week for the average physician, according to the report.

"One of the biggest issues we're seeing today with payers is added administrative work related to prior authorizations," Tina Piotrowski, CEO of Traverse City, Mich.-based Copper Ridge Surgery Center, told Becker's in March.

The concern over the administrative workload is more than just annoyance at an inconvenient process. It's a financial drain to practices and healthcare at large — and, by extension, the economy.

"We're adding a lot of administrative costs to our healthcare system just to do paperwork," Heather McComas, PharmD, said on a June 16 "AMA Thriving in Private Practice" podcast episode.

Texas passed groundbreaking legislation this year related to prior authorizations after studies showed the process was wasteful and the authorizations were granted in 99 percent of cases.

"In Texas, we have shown how burdensome the process is and how few cases are ultimately denied," Adam Bruggeman, MD, CEO of San Antonio-based Texas Spine Care Center, told Becker's in June. "The costs are extensive."

The reform in Texas is known as a "gold card" standard. When a physician shows over a period of time that certain items or services they suggest for patients are rarely denied, they are given gold card privileges and become exempt from prior authorizations for those items or services.

"The thought is that the ability of a physician to effectively test out of prior authorization could be an enormous administrative relief for doctors and their practices, especially if it's for care that they frequently provide and thus have to frequently get prior authorizations for," AMA Senior Legislative Attorney Emily Carroll said in the podcast. 

"In 36 years, I can only recall one time I could not get the test approved I wanted," gastroenterologist Carl Dettwiler, MD, told Becker's in April. "The physician generally knows better than some insurance high school graduates what is best for patient evaluation and treatment."

States including Missouri, Kansas, Colorado and Indiana have considered gold card proposals this year like the one adopted by Texas, and others including Pennsylvania, New Jersey and Georgia have considered other prior authorization reforms.

At the federal level, legislators are considering a bill that includes prior authorization reform requiring Medicare Advantage plans to improve transparency and streamline and standardize the process. The bill, the "Improving Seniors' Timely Access to Care Act," has strong bipartisan support in both the House and Senate.

If approved, the bill could be signed into law by the end of the year.

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