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Prior Authorization Issues Contribute to 92% of Care Delays

Nearly all of provider care delays are associated with inefficiencies and administrative issues with current prior authorization.

92 percent of provider care delays are from prior authorization issues

Source: Thinkstock

By Thomas Beaton

- Prior authorization issues are associated with 92 percent of care delays and may contribute to patient safety concerns as well as administrative inefficiencies, according to a new survey from AMA.

Payers should work to change their prior authorization protocols to prevent gaps in care and ensure that patients are receiving their medications, said the AMA.  

“Under prior authorization programs, health insurance companies make it harder to prescribe an increasing number of medications or medical services until the treating doctor has submitted documentation justifying the recommended treatment,” said AMA chair-elect Jack Resneck Jr., MD.

“In practice, insurers eventually authorize most requests, but the process can be a lengthy administrative nightmare of recurring paperwork, multiple phone calls and bureaucratic battles that can delay or disrupt a patient’s access to vital care,” Resneck added.

The AMA’s findings indicate that providers are likely to experience long waits before their prior authorization requests are approved.

Sixty-four percent of providers reported waiting at least one business day for a prior authorization request and 30 percent waited at least three business days.

Seventy-eight percent of providers reported that long prior authorization processes are linked to patients abandoning their treatments.

The administrative implications of prior authorization protocols also lead to poor clinical outcomes for patients, AMA found. Sixty-one percent of providers believe that prior authorizations create significant negative health outcomes.

An overwhelming majority of providers (84 percent) reported that prior authorizations create high or extremely high burden. Eighty-six percent of all provider issues with prior authorizations increased in the last five years, AMA found.

Providers spend a great deal of time processing these requests, the survey added.

Providers request an average of 13.9 prior authorizations for prescriptions in a week, and 15.1 requests for medical services each week.

Providers take 14.6 hours on average to complete these requests, which is the equivalent of two business days. Thirty-four percent of providers have staff dedicated exclusively to completing prior authorizations.

In addition, the AMA survey found that 79 percent of providers are sometimes, often, or always required to repeat prior authorizations for prescription medications.

Addressing prior authorization challenges will require providers to collaborate with payers, Resneck said. AMA has already started to work with organizations like AHIP and Anthem to create positive changes related to prior authorization.

“The AMA survey illustrates a critical need to help patients have access to safe, timely, and affordable care, while reducing administrative burdens that take resources away from patient care,” Resneck.

“In response, the AMA has taken a leading role in convening organizations representing, pharmacists, medical groups, hospitals, and health insurers to take positive collaborative steps aimed at improving prior authorization processes for patients’ medical treatments.”

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