There are few activities associated with being a doctor and running a medical practice more despised than the Prior Authorization(PA) process. Physicians and the support staff spend a number of hours a day drudging through the many specifics needed to get important medications approved from insurance companies. Cost estimates to the US healthcare system from this investment in time are $23 billion to $31 billion each year. The physicians, nurses and clerical staff are often all involved in the handling of PAs. This effort negatively impacts the providers office workflow and the provider’s ability to spend time with patients. The insurance companies state that the PA process optimizes patient outcomes by ensuring that the patients receive the most appropriate medications. I find this statement preposterous and offensive. The idea that the insurance companies are essentially overseeing the management of our patients, so that we don’t screw it up, is laughable. The insurance companies are interested in only one thing, the bottom line, the money, Making More Money. I have seen an interview of a health insurance executive who finally admitted to this fact.
The PA process works something like this, the doctor chooses a medication he ‘hopes’ that the patient will be able to get from the insurance company. This medication request is sent to the Pharmacy who sends the information to the appropriate insurance company. A denial is immediately generated and sent to the Pharmacist who then alerts the doctor’s office. The real work now begins. The office staff then devotes approximately 15 to 20 minutes per denial gathering all the information that may help get the medication approved. What is the patient’s diagnosis? What are the side effects of the drug? What allergies or side effects has the patient had in the past to medications? What alternative medications are covered by the insurance company? Has the patient tried any of these medications? Were there any problems with the alternative medications? My staff estimates that 30%-40% of the PAs are STILL denied. The staff then has to approach the physician to see if he wants to pick one of the alternative medication choices or write an appeals letter. This letter then, usually, has to be mailed. The insurance company has up to 30 days to respond and they still may deny the request.
Doctors have tried to memorize or use Aps to try to determine whether a drug will be covered but the coverage is ever changing. Looking up this information also takes time. Drug Representatives try on a daily basis to educate us on their formulary coverage but I, for one, will never be able to remember any of this information. One very helpful way to solve much of this mess, is to outsource the job to another company who can collect the necessary information related to the PA and send it on to the insurance company. Your office would then have a ‘virtual staff’ working to unload the burdens of your clinic staff. There would be no need to increase your office space, hire new employees or provide them with benefits. The virtual staff does not require vacation days or sick days. My office has found this answer to be a great alternative to doing all of this tedious work with our existing and busy staff. Since this alternative method works so well, we do not hesitate to order medications that may require a PA since we know that processing the PA will not paralyze our workflow or overwhelm our support staff. I think we may have found the answer !