Prior Authorization Cheat Sheet: Techniques and Terms

Prior authorization is a major roadblock in patient care, often delaying treatments and adding stress to your workflow. 

Despite multiple efforts, a survey by the American Medical Association (AMA) revealed that 93% of physicians reported that PA processes negatively impact patient clinical outcomes, with 24% noting that PA led to adverse events. 

Health plans use PA to reduce expenses, but it frequently interferes with patient care and adds to administrative workloads. To reduce denials, physicians and physical therapists must be aware of PA criteria, documentation best practices, and appeal tactics. A well-prepared submission shortens processing times and increases approval rates.

This prior authorization cheat sheet lists essential PA terms and techniques to expedite your workflow and obtain quicker approvals.

What is Prior Authorization?

Insurers use PA to guarantee guideline-based care, prevent unnecessary services, and keep costs under control. Under the PA rule, healthcare providers must get insurer approval before prescribing drugs, treatments, or procedures. Nevertheless, it frequently causes administrative problems and postpones treatment. 

Common Scenarios Requiring Prior Authorization

PA applies to various healthcare services, including:

• Prescription Medications: Opioids, biologics, and expensive medications frequently require approval.
• Physical Therapy: PA may be required for longer-term treatment if insurers restrict sessions.
• Diagnostic Tests: PA is frequently needed for MRI, CT, and genetic testing.
• Medical Procedures: Insurer approval is often required for advanced interventions, spinal surgeries, and joint replacements.
• Medical Equipment: PA reviews the most durable medical equipment, including wheelchairs and prosthetics.

Impact on Healthcare Workflow

PA irritates patients and providers, delays treatment plans, and adds to administrative workloads. Doctors spend an average of 16.4 hours weekly on PA requests, taking away time for direct patient care. Proactive appeals and adequate documentation are two examples of effective PA management that reduce interruptions and guarantee prompt treatment.

Key Terms and Processes in Prior Authorization

The key terms and processes are necessary to understand prior authorization. The key terms and processes are as follows:

Important Terms in Prior Authorization

Familiarizing yourself with these important terms is crucial to learn about prior authorization and ensuring smoother approvals.

1. Formulary: An insurer-determined list of approved drugs. Prior authorization is frequently required for drugs not on this list.
2. Step therapy: Lower-cost or preferred treatments must be tried before authorizing a more costly option.
3. Medical necessity: Proof that a treatment, operation, or drug is necessary for patient care.
4. Appeal: An official request to reexamine a prior authorization that has been denied, requiring corroborating medical documentation.
5. Peer-to-peer review: A dialogue to support approval between the requesting provider and the medical reviewer of an insurance plan.
6. Utilization Management (UM): A process that insurers use to assess the cost-effectiveness, necessity, and efficiency of medical interventions.

Prior Authorization Workflow

The prior authorization workflow ensures efficient management and quicker approvals for necessary treatments.

1. Submission: Physicians complete the necessary PA form and send their clinical records. Denials are frequently the result of missing information.
2. Review: Insurers evaluate requests according to cost considerations, medical policies, and guidelines.
3. Acceptance or Refusal: Acceptance permits treatment, whereas rejection necessitates further explanation or appeal.
4. Appeals Process: Providers can challenge the decision by submitting more supporting documentation or requesting a peer-to-peer review if the decision is rejected.

Efficiency Strategies for Prior Authorization

Using efficiency strategies can reduce delays and streamline the prior authorization process.

• Reduce processing time by utilizing electronic prior authorization (ePA).
• To avoid denials, provide thorough clinical explanations.
• Track PA requests to guarantee prompt follow-ups.

Delays in PA disrupt patient care. Optimizing PA management improves workflow efficiency and patient outcomes.

With a 98% approval rate and a 70% reduction in processing time, Spry automates prior authorization. Its real-time tracking guarantees quicker decisions, reducing patient care interruptions. Spry improves healthcare providers' workflow efficiency by expediting appeals and submissions.

Prior Authorization Techniques for Healthcare Professionals

PA techniques are necessary for improving approval rates and reducing delays in treatment. Here’s a breakdown of key techniques:

1. Improve Documentation: Unclear or incomplete submissions raise denial rates. Incomplete information causes many PA requests to be delayed. Add codes for procedures (CPT, HCPCS) and diagnoses (ICD-10), clinical records demonstrating a need for medicine, and failures of prior treatments (if step therapy applies).
2. Use Electronic Prior Authorization (ePA): Manual PA requests increase errors and take longer. Most major insurers accept ePA through EHR systems, expediting approvals and enhancing tracking.
3. Follow and Keep Track of PA Requests: Approvals are processed by insurance companies at different rates. Delayed reactions disrupt care. Assign workers to regularly check the status of PAs, when required, get in touch with insurers for expedited reviews, and keep a PA log for standard practices and insurer requirements.
4. Use Peer Reviews: Misinterpretations of clinical data frequently result in denials. Peer-to-peer reviews enable direct communication with insurer medical reviewers to support approval. Crafting compelling clinical arguments raises success rates.
5. Challenge Refusals Right Away: Treatment refusal does not always result from denied requests. Send appeals using more clinical proof, letters proving medical necessity, and medical associations' supportive guidelines.

PA management reduces delays and improves patient outcomes. Refining these techniques minimizes administrative burden and ensures faster approvals.

Step Therapy and Gold Carding

Step Therapy and Gold Carding both play important roles in streamlining the prior authorization process and improving approval efficiency.

Step Therapy in Prior Authorization

Before approving more expensive options, step therapy requires patients to try less expensive or insurer-preferred treatments. This procedure is frequently used to postpone necessary care, but insurers defend it as cost control.

• Before a physical therapist can receive PA for advanced interventions, they must record unsuccessful conservative treatments.
• Proof of failure with generic alternatives is frequently required by doctors who prescribe biologics.
• Even if they are clinically unnecessary, imaging tests like MRIs may need X-rays or ultrasounds before they can proceed.  

• To speed up approval, submit comprehensive clinical documentation upfront. Peer reviews can be used to point out steps that aren’t necessary.

In cases where step therapy deviates from evidence-based recommendations, appeal restrictions.

Gold Carding Reduces PA Burden

Depending on their approval history and adherence to medical guidelines, high-performing providers are exempt from frequent PA requirements through gold carding. This procedure expedites patient care and lessens the administrative burden.

Benefits of Gold Carding

• Reduces PA requests by up to 50%.
• Improves care continuity by cutting down on delays.
• Cuts down on administrative expenses for providers and insurers.

How to Secure Gold Card Status?

• Keep the approval rate for PA submissions high.
• Observe the treatment protocols specified by your insurer.
• Analyze and monitor PA data to show effectiveness and compliance.

Despite step therapy's obstacles, appropriate documentation and appeal techniques help avoid needless hold-ups. Gold carding is a long-term solution that lessens PA burdens for eligible providers.

By automating step therapy compliance and reducing delays by 70%, Spry expedites prior authorization and ensures quicker approvals for advanced treatments. Through data-backed insights, it reduces PA requests by up to 50%. With a 90% reduction in documentation time and a 98% approval rate, Spry improves patient care and efficiency.

Peer-to-Peer Review Process in Prior Authorization

The medical reviewer of an insurance plan can speak with providers directly about prior authorization denials through a peer-to-peer (P2P) review. When insurers misinterpret clinical data, this procedure aids in overturning denials.

When to Request a Peer-to-Peer Review?

P2P reviews should be started by providers at the following times:

• When there is no clinical context, denials occur.
• The insurance company demands more proof of medical necessity.
• Barriers to the best care are created by formulary restrictions or step therapy.

Best Practices for a Successful Review

The best practices for a successful review are:

• Provide Solid Clinical Evidence: Outline your patient's medical history, unsuccessful treatments, and include all supporting documentation to strengthen the case.
• Know the Insurer Criteria: Before the conversation, go over the plan's coverage policies.
• Remain Focused and Concise: Clearly state why the requested treatment is medically necessary.
• Request an Escalation When Necessary: Ask for a specialist review if the insurer's reviewer is inexperienced in the treatment field.

Impact on Approval Rates

P2P evaluations cut down on needless treatment delays. By presenting compelling clinical arguments during P2P reviews, providers improve their chances of approval and reduce appeals.

Technology and Automation in Prior Authorization

The prior authorization (PA) process has undergone a technological transformation, greatly increasing efficiency and decreasing administrative burdens. Providers can concentrate more on patient care thanks to automated systems that expedite request submissions, manage paperwork, and monitor statuses.

ePA (Electronic Prior Authorization)

Through direct integration with insurer systems and electronic health records (EHR), electronic prior authorization (ePA) enables quicker, more accurate submissions. Key features include:

• Instant decision-making shortens wait times by approving or rejecting requests instantly.
• Automating form filling lowers errors by automatically entering procedure codes and patient information.
• Thanks to real-time status updates, providers can monitor and respond to PA requests without manual intervention.

Artificial Intelligence (AI) and Machine Learning in PA

AI and machine learning increase PA efficiency by improving accuracy and automating decision-making. AI-enabled prior authorizations can automate 50% to 75% of manual tasks, boosting efficiency, reducing costs, and freeing clinicians at both payers and providers to focus on complex cases and actual care delivery and coordination.

• Estimate the likelihood of approval by analyzing clinical data.
• Mark submissions that are inaccurate or lacking before insurers receive them.
• Make immediate recommendations for enhancing documentation.

Benefits of Automation for Providers

By lowering administrative burdens, automation and AI technologies give doctors more time. Key benefits include:

• Faster Processing: Timely treatment is made possible by faster approvals.
• Decreased Error Rates: Human error in form submission is decreased by automated systems.

Healthcare providers can expedite the PA process and improve care delivery by incorporating technology and automation.

By automating the procedure, ensuring a claim approval rate of over 98%, and cutting down documentation time by 90%, Spry solves the inefficiencies of traditional prior authorization. Its AI-driven platform reduces administrative burdens, improves accuracy, and expedites request processing.

Applications of Nudging in Decision-Making

Behavioral science concepts such as nudging can help providers make more effective choices when submitting PA requests. Nudges influence provider behavior without restricting choice, which helps improve approval rates, expedite workflows, and reduce delays.

1. Default Settings

Establish defaults in PA software and electronic health records (EHR) to promote more thorough and accurate submissions. For instance, standard forms with common diagnosis and procedure codes may be pre-populated by default settings. This method expedites submission and lowers errors.

2. Simplified Checklists

Provide easy-to-follow checklists for the clinical data required. The likelihood of incomplete requests is decreased by checklists, encouraging providers to submit all necessary documentation.

3. Prompt Reminders

Include automated reminders in EHR systems to inform providers of impending deadlines or missing documents. Reminders reduce the possibility of rejections due to missed information and help ensure timely submissions.

4. Instant Feedback

Provide prompt feedback when a PA request is incomplete or incorrectly filled out. Before submitting, providers are guided by real-time suggestions to make necessary adjustments.

5. Streamlined Appeal Routes

Establish simple appeal procedures for denials. Emphasize the procedures and provide models for the required paperwork. Streamlined appeal procedures may result in denials being overturned more quickly.

Providers who use these nudges report quicker approvals for PAs, enabling more prompt treatments, less work for administrators as mistakes and delays decrease, and increased approval rates due to timely, accurate, and comprehensive submissions.

Conclusion

Healthcare delivery is greatly impacted by prior authorization (PA), but delays can be avoided, and patient care can be enhanced by streamlining the procedure. Peer-to-peer reviews, electronic tools, behavioral nudges, and accurate documentation are just a few of the essential PA strategies that providers can learn to improve approval rates and streamline processes.

Using ePA and AI-powered systems enables providers to handle requests quickly and with fewer mistakes. Understanding prior authorization cheat sheets, terminology and best practices is for smoother interactions with insurers, ultimately benefiting patients as healthcare becomes more complex. By using these tactics, healthcare professionals can focus more on providing care and less on navigating the bureaucratic complexities of prior authorization.

Spry addresses the inefficiencies of traditional prior authorization by automating the process, guaranteeing over a 98% claim approval rate, and reducing documentation time by 90%. Its AI-powered platform enhances accuracy, speeds up request processing, and minimizes administrative burdens. Schedule a demo with Spry today.