It’s now 2021, and not much has changed from the original results reported in the American Medical Association (AMA) Physician Survey on Prior Authorizations. While it is clear that prior authorization delays and denials are bad for an organization’s bottom line, the AMA released a survey of 1,000 practicing physicians that indicates they also have a significant negative impact on a patient’s clinical outcomes.
Perhaps most concerning among all the survey data is the fact that 28% of responding physicians reported that prior authorization delays or denials led to a serious adverse event — death, hospitalization, disability/permanent bodily damage, or other life-threatening events — for a patient in their care.
In other words, prior authorization reform is not just about money, it’s about lives.
Checking in on the AMA Prior Authorization Consensus Statement from 2018
In January 2018, the AMA brought together a diverse group of healthcare organizations, including the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association, to release the mutually agreed-upon “Consensus Statement on Improving the Prior Authorization Process”. This statement outlined an agreement between professional associations representing healthcare providers and health insurance plans on key reforms that each felt were needed to tackle the administrative burdens of prior authorizations and ultimately enhance patient care.
The consensus statement called on Congress to remedy the problem and a committee was formed in 2019 in the House of Representatives.
On May 13, 2021, the “Improving Seniors’ Timely Access to Care Act (HR 3173)” was finally through committee and presented on the House floor. It takes direct aim at the insurance industry’s inability to comply and would revamp the prior authorization process for Medicare Advantage patients as part of the Social Security Act. Further committee discussion is expected before a vote is called.
Where We Are in 2021
In December 2020, the AMA released a physician survey to check in on how prior authorization requirements had changed, including a year of the pandemic where insurance companies promised to reduce the prior authorization burden to support patient care during the COVID-19 public health emergency. One thousand physicians responded to the AMA Survey, and they reported that very little had changed. An unbelievable 87% of physicians said that prior authorizations still presented barriers to continuity of care.
“You would think insurers would ease bureaucratic demands throughout a pandemic to ensure patients’ access to timely, medically necessary care. Sadly, you would be wrong,” said AMA President Susan R. Bailey, M.D.
“There is no room in the patient-physician relationship for insurance-industry barriers. The AMA is dedicated to simplifying and right-sizing prior authorization so physicians can properly provide care and patients can receive the timely treatment they deserve,” Bailey said.
The Numbers Are Unmistakable
Further details from the AMA’s 2020 Survey include: delays due to prior authorizations are considerable and widespread. When physicians were asked how long their staff waited for a prior authorization decision from health plans, 65% said they waited at least one business day for prior authorizations, and nearly 30% said they had waited three business days or longer.
Delays due to prior authorizations are considerable and widespread. When physicians were asked how long their staff waited for a prior authorization decision from health plans, 65% said they waited at least one business day for prior authorizations, and nearly 30% said they had waited three business days or longer.
Now consider the fact that it takes the equivalent of two business days for each physician and their staff to complete every one of the 31 prior authorizations required every week, plus that doesn’t include the added time for follow up and rework.
In addition, 84 percent of physicians said the burdens associated with prior authorization were “high” or “extremely high,” and 86 percent believe burdens associated with prior authorization have increased during the past five years.
Unsurprisingly, more than 90 percent of physicians reported prior authorization requirements had a negative impact on patient clinical outcomes and those prior authorization procedures held up patient access to necessary care.
There is a Solution
One clear issue is the fact that over 87% of providers still utilize a manual processing workflow to manage their prior authorizations including fax machines and hours of time on hold. By implementing an advanced automation solution, such as the Infinx Prior Authorization Software, practices and hospitals could refine their entire system using AI-driven software supported by certified experts to resolve emergent approvals.
Prior Authorization Problems and Reform
Prior authorization requirements can delay the start or continuation of necessary treatment and negatively affecting patient health outcomes. These manual, time-consuming processes burden providers and divert valuable resources from direct patient care. Yet health plans and benefits managers argue that prior authorization requirements are necessary to control costs and ensure appropriate treatment.
In fact, a coalition led by the AMA urged an industry-wide reassessment of prior authorization programs to align with a newly created set of 21 Prior Authorization and Utilization Management Reform Principles. Among the 21 principles is a call to adopt a standardized electronic prior authorization transaction that saves patients, providers, and utilization review entities significant time and resources and can speed up the care delivery process. More than 100 other healthcare organizations have supported these principles.
While insurance payers were early supporters, they are seemingly unwilling to return control to the providers and now, even Congress has joined in calling for industry-wide reform.
In all, despite the AMA’s best efforts, calls for health care reform that would make the patient-physician relationship more valued than paperwork has failed to produce a significant impact.
A Prior Authorization Solution Today
Fortunately, Infinx’s Prior Authorization Software is a solution that quickly and effectively solves 100% of your prior authorization headaches, saving money and eliminating unnecessary negative patient outcomes.
Infinx’s software optimizes your prior authorization workflow, minimize denials, and maximizes turnaround time. Exceptions are automatically routed to a team of trained, certified prior authorization specialists, who can successfully complete your request on time. Automating your workflows ultimately frees physician and staff members’ time to focus on billable patient care.
Contact us today and learn how Infinx prior authorization software can simplify your workflow and increase cash flow.