Unveiling the Financial Impact of Prior Authorization

The Financial Impact of Prior Authorization

In the intricate world of healthcare, prior authorization (PA) acts as a double-edged sword. While designed as a cost-saving checkpoint within the insurance ecosystem, it comes with challenges, especially concerning the financial impact on healthcare providers and patients. So, what is this buzz around prior authorization, and how does it affect the ledger of healthcare finances? Let’s delve deeper.

What is Prior Authorization

Prior authorization is a health insurance process that requires providers to obtain approval before performing a service to qualify for payment coverage. This vetting practice’s ultimate goal is to control costs for insurers by ensuring that the prescribed treatments are medically necessary and within the policy’s coverage constraints. These prior approval requests typically pass through insurance companies or Pharmacy Benefits Managers (PBMs) before they get greenlit.

The High Costs of Prior Authorization

At face value, the PA process seems like a win-win for all parties involved—insurance cost savings and quality patient care. However, the cumbersome procedure has far-reaching financial implications affecting providers and patients. Let’s break down the costs.

Administrative Burden

The foremost impact of prior authorization is increased administrative workload for healthcare providers. The numerous complex PA requirements divert providers’ focus from direct patient care to navigating a maze of correspondence with insurance companies via phone and paperwork. This diversion leads to longer patient wait times and decreases overall efficiency, increasing operating costs for providers. A 2018 American Medical Association (AMA) survey found that practices spent an average of two business days each week handling PA requests, with some reporting spending three full-time employees on the task.

Treatment Delays and Abandonment

When it comes to managing long-term illnesses like cancer, diabetes, or heart disease, every day matters. On the other hand, weeks or even months may pass before important treatments, such as surgeries, diagnostic tests, and specialist medications, are approved. Treatment delays put patients’ health outcomes in danger and raise the possibility of expensive emergency interventions and readmissions. Sometimes, patients will completely stop taking required therapies because of the long prior authorization procedures and expensive out-of-pocket expenses.

Increased Administrative Costs

The PA process is not only time-consuming; it also comes with a price. Providers bear the cost of submitting and tracking PA requests, often through expensive electronic systems or hiring additional staff to handle the workload. Some insurance companies may even charge a fee for each prior authorization request, adding more financial burden on providers.

Patient’s Financial Impact

Patients also feel the brunt of prior authorization in their wallets. In addition to the cost of treatments, PA requires patients to pay for additional office visits and lab tests to gather supporting documentation for their prior authorization request. Moreover, if a treatment is denied, patients may have to shoulder the financial burden themselves.

Finding a Balance

The financial impact of prior authorization on healthcare providers and patients is undeniable. However, the process’s intended purpose is to control costs for insurance companies.

Finding a balance between cost control and minimizing the financial impact of prior authorization on providers and patients is essential.

Streamlining the PA process through electronic systems, reducing approval timeframes, and eliminating unnecessary requirements can ease the administrative burden on providers and reduce patient treatment delays.

Understanding the Financial Impact

Increased Administrative Costs

The PA process is infamously tedious, involving paperwork, persistent follow-ups, and sometimes complex negotiations. These additional administrative tasks require substantial staff time, leading to higher operational costs.

Delayed Patient Care and Revenue

When treatment is gated behind the authorization process, not only can patient care be delayed, but also the associated revenue. When timing is critical, this can hinder the quality of care and impact a healthcare facility’s financial cycle.

Potential for Denied Claims and Lost Reimbursements

Denied claims are an immediate financial blow. They mean redoing paperwork, reapplying for authorizations, and, potentially, never receiving payment for services rendered, directly affecting a provider’s bottom line.