Prior Authorization Still a 'Pain Point' for Providers

MedPage Today, February 23, 2017

An AMA survey found that practices reported submitting an average of 37 prior authorization requests each week, with an average of 16 hours of physician and staff time to complete them.

This article first appeared February 22, 2017 on MedPage Today.

By Joyce Frieden

The healthcare industry hasn't eliminated the hassles for providers that prior authorization often entails, but they're getting closer, several speakers said here at Healthcare Information and Management Systems Society (HIMSS) annual meeting.

"Studies have shown that prior authorization is the biggest 'pain point' among providers," Pam Jodock, senior director of healthcare business solutions at HIMSS, said at a Tuesday morning meeting session. "The issue is not automation; it's the business processes to which automation would be applied."

The six groups represented at the morning session are hoping to develop consistency in the requirements for getting a prior authorization and reducing the number of treatments and procedures that require it, she added. "The fact that we have six [groups represented] is because this is a critical issue of everybody on the stage today."

Standardizing the Transaction
Bob Bowman, an associate director at CAQH CORE, an organization focused on streamlining healthcare business processes, said that his group has been working on prior authorization for 3 or 4 years. CAQH has developed a rule set to standardize prior authorization transaction, which includes "basic infrastructure requirements, response times, connectivity, and time-stamping," he said.

CAQH CORE also has established a six-member prior authorization advisory group that is trying to find more issues to address in this area, said Bowman; he noted that a 2016 CAQH survey found that the adoption of a standardized form—known as 278—mandated by HIPAA for prior authorizations only had an 18% adoption rate.

"Prior authorization is a huge issue," said Heather McComas, senior policy analyst at the American Medical Association (AMA). "We hear about this issue all the time from our members. Even more than that is the patient impact; they see that care can get delayed by this process and it really upsets them."

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