One of the biggest historical rifts between health plans and providers has been rules that require physicians to clear procedures, tests, and even medications with a patient’s health plan before they are administered.
Each side has conceded ground on this issue over the years—providers accepting preauthorizations as a way to help control costs and insurance companies loosening their policies to give physicians greater discretion. But that hasn’t’ stopped the two from taking jabs one another.
The latest from healthcare providers came in the form of an American Medical Association survey in which 2,400 physicians weighed in on their preauthorization experiences:
- More than one-third of physicians said they experience a 20 percent rejection rate from insurers on first-time preauthorization requests for tests and procedures, with 46% indicating they have difficulty obtaining approval from insurers on 25% or more of preauthorization requests for tests and procedures.
- Nearly two-thirds of physicians said they must wait several days to receive preauthorization from an insurer for tests and procedures; for 13%, the wait more than a week.
- Sixty-four percent of respondents stated they found it difficult to determine which test and procedures require preauthorization by insurers, and 67% reported difficulty determining which drugs require preauthorization by insurers.
"Intrusive managed care oversight programs that substitute corporate policy for physicians' clinical judgment can delay patient access to medically necessary care," said AMA Immediate Past President J. James Rohack, whose organization estimates that physicians spend 20 hours per week on average dealing with preauthorizations at a cost of $23.2 to $31 billion a year.
The study’s results were less than phenomenal, confirming a fact that we all know: preauthorizations are a pain in the posterior, which was confirmed in AMA’s conclusion that preauthorizations weren’t so much a bad thing, just something to be improved upon.
"Nearly all physicians surveyed said that streamlining the preauthorization process is important, and 75 percent believe an automated process would increase efficiency," Rohack stated. "The AMA is urging health insurers to automate and streamline the current cumbersome preauthorization process so physicians can manage patient care more efficiently."
No argument here, say health plans. “We agree with physicians and AMA that it’s important to address the issue of efficiency,” according to trade association America’s Health Insurance Plans spokesperson Susan Pisano. “At the end of the day, we all want the same thing. We want patients to be treated in a safe and effective manner.”
According to Pisano, AHIP is sponsoring projects in which healthcare payers are collaborating with physicians to address how to improve efficiencies in the preauthorization process. Among them, five major health plans in New Jersey in collaboration with several provider organizations are investigating a single channel—in this case a Web portal—that provides physician access to multiple insurers to streamline administrative tasks such as checking claim status and preauthorizing services.
But let’s not take this as a sign that health plans and providers are in complete agreement. While declining to comment specifically on AMA’s survey, Pisano defended insurers’ preauthorization practices saying that its used much more selectively now days. “Generally these are things where there is a lot of variation between practices or there is documented concern about overuse and patient safety.”
So while physicians will continue to cringe at the notion that their judgment is being undermined while health plans stick to their guns on PPPP (profit-preserving preauthorization policies), let's enjoy this moment when both groups are working simultaneously to make at least the administrative function more efficient.