Insurance Providers Should Prioritize Solutions for Streamlining Pre-Authorization Processes

Prior authorization wastes medical and insurance providers’ time and can result in poor patient outcomes. Changes are likely as the federal government reviews legislation. Melanie Musson, a health insurance expert with USInsuranceAgents.com, reminds providers, “Health insurance providers should focus on creating better pre-authorization processes to improve efficiency and patient outcome.”

Prior authorization has been a standard component of the insurance provider and medical provider relationship for a long time. Recent studies indicate that this system has grown out of control. As a result, insurance providers deciding on claims coverage can waste provider resources and hinder patient access to lifesaving tests and treatments.

State Legislation Leading the Way

Several states have addressed prior authorization problems and passed legislation to improve patient access. For example, in Texas, medical providers who have demonstrated 90% pre-authorization approvals over six months are exempt from obtaining pre-authorization before specific procedures for diagnosing and treating patients.

In another example, Oregon requires insurers to respond to non-emergency pre-authorization requests within two days. Unfortunately, pre-authorization decisions can take two weeks or longer in many areas of the country.

Federal Government Working on Legislation

The federal government is working on legislation to improve prior-authorization procedures. While specific changes and regulations are yet to be established, insurance providers should prepare for significant changes.

The federal government is primarily concerned with Medicare and Medicaid pre-authorization because that’s where they’re most invested and responsible. 

Insurance Provider Response to Probable Regulation Changes

While pre-authorization processes seem to protect insurers from paying for unnecessary procedures and testing, it may also prevent policyholders from accessing essential care. 

That may result in advanced illness that costs the insurer more to treat. In fact, according to the American Medical Association (AMA), about one-third of physicians report that prior authorization requirements have resulted in adverse health outcomes in patients. 

Automation in processing prior authorization is one avenue to consider to improve the current system. That may speed up the process. 

Insurance providers should also consider the pros and cons of building measurable pre-authorization results like Texas has established. Then, insurance providers can reward physicians and health groups that consistently offer necessary and not superfluous treatments and tests by waiving pre-authorization for specific procedures. 

Physicians and practices should be able to build trust with insurers so they can avoid spending valuable resources on paperwork and working through red tape.

While changing rules can cause insurance providers procedural headaches, improving the preauthorization regulation should improve both patient and provider outcomes.