It doesn’t matter if you’ve recently completed your sleep medicine fellowship or have been a board-certified specialist for many years, prior authorization (PA) for procedures and the associated equipment and medication are a necessary pain that simply can’t be avoided.  While the symptoms of sleep disorders:  loud snoring, weight gain, hypertension, trouble concentrating, gasping for breath, are undeniable, insurance companies will require providers to document the necessity of treatment before agreeing to reimburse.

PAs create frustration in sleep medicine in a variety of ways, including:

  • delaying patient care for up to three or more weeks
  • causing a provider to alter their treatment plan for expediency (at home vs. in-clinic studies)
  • being more susceptible to review and rejection because of insurance company bias
  • being administratively burdensome taking several hours to several weeks to complete
  • negatively impacting the scheduling process and, ultimately, the patient experience

The American Academy of Sleep Medicine (AASM) recently responded to the Centers for Medicare and Medicaid Services (CMS) call for input regarding PAs, stating that in their efforts to increase advocacy efforts, they strongly recommended changes that would reduce administrative burdens placed on their membership.  Additionally, the AASM signed onto the American Medical Association (AMA) letter expressing strong concerns to the House of Representatives Committee reviewing H.R. 3107, the Improving Seniors’ Timely Access to Care Act, meant to streamline and standardize the PA process through Medicare.

3 Ideas to Make the Prior Authorization Process More Effective

Regardless of the industry stakeholder intention, it doesn’t appear that PAs are going to go away completely.  Instead it’s more likely that insurance companies will reign supreme, and they will continue in some (hopefully) streamlined form.

No matter how frustrating, they do seem to help curb healthcare costs.  So the question may be how to make them practical  for you in your practice while reducing the administrative burden and costs and improving revenue?  Let’s look at three ways you can make the process more functional:

    1. Always submit organized, clear documentation — Understanding that insurance will likely question any request for in-clinic sleep studies, and expensive equipment and medication, documentation becomes key, including all provider clinical notes.

      Implement a protocol or EHR template that ensures comprehensive documentation.  Understand and stay ahead of what they are going to request, making sure to complete PAs fully.

      Be sure to include medical criteria that insurance companies often ask for, including BMI, neck circumference, history of snoring, length of symptoms.

    2. Be prepared for clinical review on in-clinic or assisted studies — Most insurance payers will elongate the approval process calling for clinical review or outright reject the request.  On the other hand, most insurance payers don’t even require a PA on an at-home study signaling their strong desire to funnel patients to that alternative regardless of appropriateness.

      Be ready to submit organized, concise, well-articulated appeals with all supporting information.  Under the Affordable Care Act, all insurance payers are required to have an appeal process in place.  Ask for a 72-hour expedited or urgent review to speed the process along even further.

    3. Consider an automated prior authorization process — Engaging advanced automation means using AI-driven software that is secure, comprehensive, and electronic.  Linked to the EHR/EMR system, PA information can be collected, submitted, and followed up 24/7 in real-time.

      When using an automated PA system, there is a significant opportunity to reduce administrative time and costs, as well as schedule patients much more efficiently.  And should an appeal be needed, an automated system would generate and submit the appeal based on pre-defined parameters with associated documentation.

While there has been growing discord about PAs for many years with major governmental and industry-representative bodies joining the chorus, little has changed. Even if there are foundational improvements considered, the PA process will likely continue in a new form, but still requiring clinician and administrative time to manage.  Being proactive in facilitating an efficient process seems to be the best solution.

Contact us to learn more about automating your prior authorizations for sleep medicine.