The Critical Role of Prior Authorizations in Infusion TherapyCarolyn Dutton, MD, FACP, FACEP, ACPA-C As physician advisors, we understand the complexities and challenges of navigating the healthcare system. Most advisors are well versed in inpatient level of care authorizations, but does your organization have a need for authorization expertise in the outpatient setting? One of the most critical aspects of ensuring smooth operations and patient satisfaction is managing the authorization process for medical procedures and treatments. While it might seem tempting to address issues post-claim, obtaining prior authorization offers significant advantages over fighting denials on the back end. Prior authorization helps reduce administrative burden and streamline the process. By securing approval before the procedure, the time-consuming and often frustrating task of appealing denied claims can be avoided. Appeal overturn rates are dismally low compared to favorable organization determination rates. This proactive approach allows your team to focus more on patient care than paperwork and allows your appeals team to focus on other denial areas. A significant benefit of a successful prior authorization is an enhanced patient experience. Knowing that their treatment is approved in advance reduces anxiety and uncertainty. It also prevents unexpected financial burdens, as patients are less likely to receive surprise bills for denied claims. They are also less likely to complain to the hospital and their physician about their denied care which in turn leads to higher patient satisfaction and trust in the healthcare system. This financial predictability allows for better resource allocation and planning within your practice. For healthcare organizations, prior authorization ensures financial stability. While authorization is no guarantee of payment, as we have repeatedly heard, it certainly increases the chance that the provided services will be reimbursed. Another patient dissatisfier is that denials contribute to patients not reaching their out-of-pocket maximum and overall higher costs. Infusion therapy is often done for chronic comorbidities requiring recurring high dollar medications. Drug manufacturers frequently offer co-pay assistance and require an explanation of benefits (EOB) assigning patient monetary responsibility prior to their application. Without this EOB, companies will not apply the financial assistance, and a $20 co-pay can quickly become a $1,000 bill. In conclusion, while the prior authorization process may seem cumbersome at times, its’ benefits far outweigh the challenges. By securing approval upfront, physician advisors can reduce administrative burden, streamline operations to result in a clean claim, enhance patient experience, and ensure financial stability. Embracing prior authorization is a proactive step towards a more efficient and patient-centered healthcare system. Dr. Dutton is Director of Business Operations for Physician Advisor Services at Atrium Health in Charlotte, NC |