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Analysis

Docs Complain to Congress About Prior Authorization Hurdles

By John Commins  
   September 12, 2019

Physicians say prior authorization creates undue time burden and administrative costs.

A House committee on Wednesday heard complaints from four physicians about the hassles of prior authorization and its ill-effects on patients.

"While there may be a limited number of justifiable cases where prior authorization is appropriate, it is clear that health plans more often require prior authorization as a cost-containment strategy by limiting and restricting access to specific services," John Cullen, MD, president of the American Academy of Family Physicians, told the House Committee on Small Business.

"In submitting prior authorizations, family physicians and their staff spend countless hours reviewing documents, processing paperwork, checking boxes, and waiting on hold to talk to health plans to meet their often arbitrary and not evidence-based requirements so that our patients can get the care they need," he said.

Cullen's testimony was echoed by his physician colleagues before the committee.

"In one year, my practice dedicated over $80,000 in resources for prior authorizations," said Dave Walega, MD, Chief, Division of Pain Management at Northwestern University Feinberg School of Medicine in Chicago.

"If the same costs and circumstances were incurred in a small group medical practice, it could be financially devastating to have overhead costs rise so high," he said.

Paul Harari, MD, chairman of the American Society of Radiation Oncology, said "prior authorization is intended to minimize health care costs, but this is often done at the expense of a patient’s well-being."

"Nationwide, physicians and their patients are bearing the brunt of excessive prior authorization practices," he said.  

"Physician practices are on the frontline – and complying with management utilization has driven up the cost of running a medical practice," said Howard Rogers, MD, a Connecticut-based dermatologist, speaking on behalf of the American Academy of Dermatology Association. "On average, dermatologists dedicate eight hours per week solely to administrative activity; precious time they could be otherwise dedicating to patient care."

"Prior authorization is one of the most unbalanced approaches to utilization management in terms of increasing practice costs while providing no increase in quality of care and regularly delaying patient treatment," Rogers said.

The physicians got a receptive ear from subcommittee Chairwoman Nydia M. Velázquez (D-NY).

"When doctors spend hours dealing with paperwork or can't treat a patient because a health insurance company won't approve a treatment, the result is patients suffering," she said in opening remarks. "And that is why we are here today–to discuss a barrier preventing family physicians and specialists from providing critical care to their patients."

Velázquez said that while prior authorization is a vital tool used to reduce care costs and advance evidence-based medicine, "it's also putting an undue burden on physicians, their staff, and patients. It is not uncommon that patients now face delays of two weeks and sometimes over a month before getting treatment."  

America's Health Insurance Plans and the Blue Cross Blue Shield Association submitted a joint statement to the committee, citing statistics that "65% of physicians reporting that at least 15-30% of care is unnecessary."

"Needless medical tests harm patients and waste billions of dollars every year; $200-$800 billion is wasted annually on excessive testing and treatment," the payers said. "Medical management ensures patients have access to safe and clinically-effective health care services and addresses this type of waste in our health care system."

The payers said that prior authorization is a valuable tool in the fight against healthcare fraud. They also said they were working with providers and the federal government to reduce the paperwork and procedural burdens for physicians. 

“Nationwide, physicians and their patients are bearing the brunt of excessive prior authorization practices.”

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.


KEY TAKEAWAYS

Physicians say the costs of gaining prior authorization can be 'financially devastating' for small practices.

The payers say prior authorization is a valuable tool in the fight against healthcare fraud.

They pledge to work with providers to reduce the paperwork and procedural burdens for physicians. 


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