Do Prior Authorization Requests Hurt Patient Care?

Cheryl Alkon is a freelance medical writer based in Massachusetts.

What Will Improve the Preauthorization Process?

Several ideas could help make the prior authorization system easier on physicians and, ultimately, on patients:

  • Be aware of policy. Familiarity with payer policy is important, said Dr. Setzen. Additionally, knowledge of clinical practice guidelines and other tools from the American Academy of Otolaryngology–Head and Neck Surgery and other professional societies in the specialty can help guide appropriate testing and treatment that can help prevent payer denials.
  • Encourage payers to incorporate specialty-specific peer review. For example, if insurers had otolaryngologists evaluating otolaryngology claims, the prior authorization process could be streamlined, said Dr. Gold.
  • Push for merit-based approvals. Payers could consider physician performance as a way to cut prior authorization entirely. “Years ago, one company said they would give a status to the individual practitioner who had [been] shown to deliver excellent care,” said Dr. Gold. As a result, the company would allow the physician to skip prior authorization entirely. “Maybe [payers] could come up with a merit system, such as, out of 100 scans in the last six months, if 100 passed, the practice or physician wouldn’t have to require pre-authorization anymore,” he suggested.—CA