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Ophthalmologists are admonished to maximize efficiency and decrease overhead, even as the complexity of practice makes this increasingly difficult. One of the significant contributors to this complexity is the expansion in prior authorization requests. Dave Dopp, the administrator at my ophthalmology practice, borrowed the name of the children’s game “Mother May I?” to describe the growing burden of preauthorization requests.
These requests have long been a tedious task, but their volume has increased dramatically in recent years. For example, the number of drugs covered by Medicare Part D plans requiring prior authorization has almost tripled, increasing from 8% to 23% since 2007. Historically, health plans claimed that their preauthorization requirements were in the interests of patient safety when powerful new drugs with potentially serious side effects emerged. But more recently, the new drugs used by ophthalmologists—such as anti-VEGF agents—are usually well tested and safe, but very expensive. Drug plans now unabashedly admit that prior authorization has evolved into a technique to limit costs and to ensure that physicians take a stepwise approach before using costly medications.
Preauthorization (and predetermination) is also commonly required for a wide range of procedures, tests, and materials, including blepharoplasty, ptosis repair, MIGS, glaucoma shunts, corneal graft tissue, amniotic membrane, imaging, and even cataract surgery.
How much time do physicians and staff spend in preauthorization activities? According to study results published in Health Affairs, physicians overall report spending an average of 3 hours per week interacting with health plans, including work on preauthorization requests. Surgical subspecialists spend less, about 2.1 hours per week.1 Our clerical staff spends much more time—an average of 5.9 hours per day per physician. Interestingly, clerical time spent per physician was higher for small practices than for large practices.
One of the challenges is that each health plan has a different form, a different protocol, and a different preferred mechanism for communicating. In a white paper on preauthorization issues, the American Medical Association recommended a standardized electronic form, transparent and standard preauthorization requirements, consistent application of utilization review criteria, limits on requests for medical record review, and consistent response times from payers.2 The AMA points out that this approach would decrease costs for payers as well. But until these standardized protocols are implemented, how can ophthalmology practices manage the complexities of preauthorization requests?
First, a practice can analyze its payers and learn the processes for each of the relevant major health plans. At least one staff person can become an expert on the requirements for the major payers, although it can be incredibly complex if a practice interacts with more than a few health plans. For example, is there a standard form? Does the payer prefer fax, electronic submission, or a phone call? By collecting all of the required information before submitting the request, the staff expert can help to reduce bounce-back. The practice can implement a system to track a request throughout the process and review the workflow. This can also reveal any patterns in preauthorization denials. Finally, some ophthalmology practices engage a third-party vendor to manage the preauthorization process for medications.
Our frustration with preauthorization requests parallels our general frustration with the emerging health system. We are shifting to a system that aims to pay for value—yet that very system is cumbersome and inefficient. Although the process of “Mother May I?” is likely to grow, standardization of the processes, transparency of criteria, and consistent response times would ease the burden on physician offices.
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1 Casalino L et al. Health Aff. July/Aug. 2009;28(4):w533-w543.
2 American Medical Association, Private Sector Advocacy. White Paper: Standardization of prior authorization process for medical services. June 2011.