Techniques to Reduce Prior Authorization Burden
The AAFP is committed to identifying techniques to help reduce—even eliminate—your prior authorization burden without compromising patient care. Techniques for successfully navigating payers’ prior authorization requirements can be categorized into three primary areas:
Prescribe Mindfully
Any prior authorization that can be avoided in the first place will prevent downstream burdens. Review tips that can help.
Streamline & Delegate
From built-in rules and templates to cheat sheets and workflows, discover how to develop workflows to streamline and delegate prior authorizations.
Push Payers
Learn how other practices use the appeals process and direct communications to push payers for fewer prior authorizations and faster processing.
Physicians and their staff have set up systems to try and order cheaper evidence-based drugs, tests and treatments that do not require prior authorization. Each prior authorization carries the burden of time, effort, and delay, so any that can be avoided in the first place will prevent associated downstream burdens.
Ways to enact:
- Identify safe but cheaper alternatives to high-cost drugs
- Prescribe based on evidence-based guidelines
- Choose generic drugs when possible
FPM: 13 Ways to Reduce the Burden of Prior Authorization
Seeking prior authorization from insurers for certain types of services is a regular headache for family physicians. However, physicians and their staff can take several steps to lessen the burden. Here are more than a dozen ideas.
Practices have built rules and cheat sheets into their EHRs and workflows to help address prior authorization requirements. They have delegated prior authorization to dedicated staff, freeing others to focus on care. Your team and EHR can be used to your advantage.
Steps to follow:
- Create master lists of medications and procedures that require prior authorization, broken down by insurer, and alternatives that do not require it. Program your EHR to alert you when you order something that regularly requires prior authorization.
- Be especially thorough with your documentation when ordering treatments or services you know do not follow the standard guidelines.
- Create prepopulated forms, ideally using the insurer’s own forms, listing codes, diagnoses, and other information the insurer typically requires to process a prior authorization.
- Submit requests electronically and use technology (a portal or EHR) to upload supporting documentation instead of faxing it.
- Designate one or more dedicated staff to submit prior authorizations.
Practice Hack: Prior Authorization Tips
Learn how to navigate issues physicians commonly encounter when working with private health plans.
Workbook and Cheat Sheets
Streamline prior authorizations using this free resource to help you manage your process. AAFP membership required for access.
Physicians and their staff have successfully used the appeals process and direct communications to push payers for fewer prior authorizations and faster processing. Physicians can also educate their patients to direct their frustrations with delayed treatment at payers rather than the practice.
Tips to consider:
- Demand that deadlines be met
Push insurers to meet their own deadlines for turning around prior authorization requests. - Use the appeals process
If denied, use the payer’s appeals process. Keep track of appeals and how long until an insurer must make a decision. - Talk to the payer’s physicians
Leverage a payer’s peer-to-peer process. Speaking with the insurer’s medical director or other physician available to speak with physicians about prior authorization issues can clear up problems much faster. - When all else fails, fight
Some physicians send a form letter defending their use of a particular medication or pointing out the dangers of changing patient drug regimens, while others threaten to send the insurer a bill for their time. Some also recruit their patients to send letters to their insurer. Consider also sending letters to your state insurance commissioner.
AMA: Prior Authorization Practice Resources
The AMA offers various reform resources, as well as research and reports, to help minimize the current impact of prior authorization on practices. Get additional insight and guidance by viewing the AMA’s three-part ePA video series.
