August 25, 2016 | Prasad Gunasekaran, MD
Advocacy

Spectrum of the Problem

Contemporary clinical practice involves pre-authorization from insurance companies for procedures. These were initially designed to obviate the need for discrepancies in payments for medical care, already provided by physicians. However, it has evolved into a labor-intensive process, causing considerable delays in patient care. Depending on the clinical scenario, the process of pre-authorization typically involves up to three burdensome steps:

Step 1: Clinical review involving a non-clinical staff member and an insurance official. This involves submitting clinical records and waiting for a response (Average processing time of 30 minutes).

Step 2: Nurse clinical review: involves a registered nurse who reviews clinical data with an insurance official (Average processing time of 10 minutes).

Step 3: Peer-to-peer review: a third level of review between a physician or a mid-level provider and a similarly qualified individual from the insurance standpoint (Average processing time of 10 minutes)

One may spend up to an hour depending on the clinical scenario. There is often a delay of 20-30 minutes while waiting to be connected to the appropriate person. A lack of standardization is noted since the same procedure may be subjected to different levels of review in different patients, translating into disparate time frames for approval.

For procedures which are performed in accordance with the appropriate use guidelines and substantiated with apt documentation, this process imposes a large burden on time and manpower. In this era of steadily increasing clinical demands where incentives are based on clinical productivity, physicians are hard-pressed for time. More importantly, patients who need care in a timely manner are subjected to delays caused by a process which is neither time-efficient not transparent.

States Moving Towards Standardized Insurance Preauthorization

States such as Ohio have successfully passed a bill (S.129) which negates delays by formulating an online-system for pre-authorization. This bill mandates complete disclosure of all rules pertaining to pre-authorization  by insurance companies, faster pre-authorization  approval for urgent procedures, provision for retrospective reviews for unexpected procedures  performed during an authorized procedure and  obviates retrospective payment denials for procedures completed within 60 days of pre-authorization.  This achievement was spearheaded by ACC’s Ohio Chapter in conjunction with the Ohio State Medical Association.

Health Bill 1657 has been successfully introduced in Pennsylvania. The key components to this bill include formulation of a standardized pre-authorization form for physicians, establishing standards and limiting overuse of pre-authorization and enhancing processing times by introducing electronic pre-authorization processes.

Similar efforts in the state of Washington resulted in the engrossed substitute S. 6511 which mandated final decisions to be made on pre-authorization for urgent procedures within 48 hours, non-urgent procedures within five calendar days and post-service review requests within 30 calendar days. Presently, up to 15 states are advocating for transparency in the pre-authorization process.

H.B.381 passed by the state of Delaware has made it imperative for insurers to report data pertaining to pre-authorization approvals, denials and appeals to the Delaware Health Information Network on-demand and at least twice annually.

How can FITs and ACC chapters make a difference?

• Present the issues to local legislators and the state insurance commissioner. FITs can compile an agenda which details the lack of transparency and standardization in the pre-authorization process, and how it adversely affects patient care. For change to occur, we must present our agenda to the legislators. Even hallway meetings in the state assembly with the senators could pave way for physicians to establish meaningful discussions in the future.
• A concertized effort from the local ACC chapter, state medical society and local/state hospitals must be undertaken towards meeting the legislators. Concerns with the pre-authorization process are a common denominator for all physicians across the country, but laws are different across states. A multi-disciplinary team comprising of the ACC chapter governor, representatives from the state medical council, FITs, registered nurses and administrative staff offers impactful taskforce compared to individual representation. Hierarchical diversity is often appreciated by lawmakers.
• Provide data to the legislators from individual clinical practices on the average time spent on pre-authorizations for urgent and non-urgent medical interventions per patient along with approval rates. Claims are best represented when backed by robust data.
• Invite legislators and schedule practice visits for local representatives in the state assembly. It provides a bird’s eye view for the lawmakers on the time and effort involved with patient care and also underscores delays in patient care caused by the heterogeneity in the pre-authorization process. This can serve as a quality improvement project for FITs.
• Follow-up with legislators. Follow-up emails, meetings or letters are strongly advised. This strengthens the connection with your local lawmakers and facilitates grass-root understanding of issues affecting patient care.

Resources Available for FITs

• ACC Chapters: Be active in your state chapter. Indicate your willingness to either spearhead an advocacy initiative or be an active member of a team.
• ACC Advocacy and ACC’s Political Action Committee (ACCPAC): Join the ACC advocacy’s efforts by getting involved in the ACCPAC. ACC Advocacy staff are useful resources.  
• ACC Advocacy Action App: This app provides a link to your state and congressional directories.  
• Templates for practice visit invites and follow-up letters: Use the ACC advocacy app to download these templates and letters.

Our Voice Matters!

The onus is on physicians and the care team to advocate for a transparent, standardized and time-efficient process with a focus on providing effective patient care and improving outcomes. Our patients are entitled to timely medical care and we are vested with the responsibility to advocate for them. Our voice matters! Get involved!

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This article was authored by Prasad Gunasekaran, MD, a fellow in training (FIT) at the University of Kansas.

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