Blue Promise: Prior Authorizations: Red Tape or Right Care?

Sometimes patients experience a wait time before they receive the planned medical care suggested by their doctor. If their doctor already recommended the treatment, then why is there a delay? Dr. Leslie Weisberg, Executive Medical Director of Plan Performance, and Alyce Kuhn, Vice President of Market Clinical Operations, share insights about prior authorizations in this episode of Blue Promise. 

You can listen to the complete discussion on Apple Podcasts  , SoundCloud  or wherever you listen to podcasts. You can also watch the video recording of this podcast on YouTube 

Blue Promise is a podcast and online video blog that aims to address complicated health issues with candid conversations from subject matter experts. New editions are published regularly and are hosted by Dr. Dan McCoy, President of Blue Cross and Blue Shield of Texas, and his co-host, Ross Blackstone, Director of Strategic Influence. 

Show Transcript

DAN: Sometimes patients experience a wait time before they receive the planned medical care suggested by their doctor. It can be confusing if their doctor already recommended that treatment, then why is there a delay. Thanks for joining us for this edition of Blue Promise. I'm Dr. Dan McCoy. I'm the President of Blue Cross Blue Shield of Texas. I'm here with my co-host Ross Blackstone. 

ROSS: All right. Dr. McCoy we're so we're talking about something called prior authorizations. We have two experts here to speak with us. Dr. Leslie Weisberg is a Executive Medical Director of Blue Cross Blue Shield of Texas and Elise Koon is Vice President of Market Clinical Operations. Thank you both for being here. 

DAN: So let me ask you a quick question so I think most people probably know but kind of walk me through how this process works. So what is a prior authorization like what does that mean. 

ALYCE: A prior authorization is before the services rendered. So of the provider will submit the appropriate you know there may be a service   

DAN: So let me give an example like it like a knee replacement, so that patient needed, I'm a doctor and my patient needs a knee replacement. So what happens? 

ALYCE: The provider will, if it if it's a non-emergency the provider will submit the clinical information necessary to be reviewed by clinicians depending on you know what the services but for knee replacement the nurse reviewer will review the case and they review against the medical guideline and or the medical policy and determine if it meets the appropriateness of care and at the right place of service if it doesn't then it goes to a medical director for review 

DAN: Which is a physician 

ALYCE: A physician. 

ROSS: So it determines whether or not that treatment is going to be covered by the patient's health insurance. 

ALYCE: That's correct. Determines if it will be approved or if there would be an adverse determination. 

DAN: Let me ask you a question here. Just a clarification. I think there's a really important issue is this. Does the member play a role in any of this or is this all between the doctor and in the health plan? 

ALYCE: It's in their member benefit book for coverage. There are certain things the member has responsibility for in certain benefit plans such as ensuring that their provider does submit a prior authorization. 

DAN: For the most but for the most part this is a conversation between the health plan and the doctor. 

ALYCE: That is correct 

ROSS: And that's why it's so controversial, Dr. McCoy, the provider community sees this as being pretty burdensome. They say that they spend about 16 hours a week on prior authorizations, now most of that comes from nursing staff but doctors do spend about one hour a week on prior authorizations and they say that it costs about two to three thousand dollars each year. Ninety two percent of health care providers say that it has a negative impact on clinical operations. So you know this is this is what people are saying out there. Dr. Weisberg knowing that why do we do prior authorizations are they even necessary. 

LESLIE: So I do believe prior authorizations are necessary. It gives us as Alyce was saying a mechanism to make sure that our patients are getting the most appropriate and cost effective care. It also helps to limit fraud waste and abuse which again helps with the cost effectiveness of the care as well as premiums for our members. 

ROSS: So another component of that is that it can help to increase safety. There was a study published in the American Journal of Managed Care that found that prior authorizations actually reduced the number of opioid abuse instances by 11 percent and reduced opioid overdoses by 25 percent and it reduced prescriptions for longtime opioid users by 15 percent. So there's a component of this that can help identify maybe drugs that would counteract with each other inappropriately making sure that all the doctors on the same page. Its important to have one entity looking at the big picture right.

LESLIE: Right. In addition to that it also decreases the utilization of experimental investigational and unproven procedures again to ensure that our members are getting no care that's based on evidence based medicine. So that's another factor in the rationale for doing prior authorizations. However we do realize it can be a burden at times and so we definitely want to work with our partners in the community to see if we can still perform the prior authorizations. And that's why we review on a regular basis what services we do offer or we require I should say as prior authorizations. 

ROSS: Are emergencies part of that? 

LESLIE: Typically services provided in the emergency room and do not require prior authorizations. Some services are considered urgent or emergent. And in those cases they may require prior authorizations. What we recommend doing is that in any questionable case or concern to definitely call the Customer Service to determine if it's necessary. 

ROSS: So America's Health Insurance Plans says that prior auth's really apply to only about 15 percent of treatments. Maybe if you guys could give us an example or tell us which types of treatments which type of care which type of prescriptions require prior authorizations. 

ALYCE: I’ll focus on certain types of services and place of service like inpatient care requires prior authorization not only to determine the medical necessity of that inpatient care but also determine if you know it could be performed at a lower of care. Like an outpatient or maybe the member could be home with home health with I.V. therapy. It also requires prior authorization to ensure we're used to having appropriate discharge planning at the time of admission to identify what's going on with that member at that time so we can ensure you know through the patient's treatment plan that they're getting the best service and they're in the right place. Other services such as outpatient services require a prior auth for 2019 it'll be advanced imaging, some of those high cost imaging such as you know cat scan MRI PET scans as well as some specific surgeries that are considered high cost and sometimes overused such as lumbar spine and things like that. 

DAN: So Alyce let me ask you a question real quick. So aren't we disagreeing with the decision of their local doctor. So how does that work. I mean the physicians already made a decision about this procedure and is someone second guessing the doctor? 

ALYCE: No not really second guessing the physician may not have all the information in terms of the evidence based guidelines and what's clinical efficacy. So he may decide he wants to do a surgery but then there are other treatments that maybe need to be done before that surgery. As you know so many surgeries not only are they you know they could be you know they can be difficult for the member there can be untoward outcomes at the surgery. So that's why one ensure the most effective treatment plan and procedure that's medically necessary that you might add in anything Leslie.  

LESLIE: No I mean I agree with that. 

DAN: So the goal then really is not necessarily just the cost, the goal is actually a better outcome for the member.  

ALYCE: Correct.  

DAN: That could be medical, social and financial. I mean it's not just an issue related to a financial decision. This is really more an issue related to the global and holistic houtcome for the member.  

ALYCE: That's correct. 

ROSS: And that's hard. I would imagine sometimes to understand when you're when your doctor tells you need this treatment and then yet you have to wait an undetermined amount of time. It's hard to kind of process and accept that and to look at the long term picture so let's talk about the time. How long does it usually take to approve prior authorizations. 

ALYCE: We follow the guidelines of the state of Texas for the Department of Insurance so you know there are guidelines for urgent or you know nonurgent procedures like for inpatient maybe 24 to 48 hours for routine it may be you know 72 hours or you know depending on the time frame so. So there are different guidelines that we adhere to. We certainly try to prioritize and get all requests reviewed in a very timely manner because we know that members you know they want to hear you know when they can schedule their surgery or you know or whatever. But we look at those. We also monitor them and we monitor the turnaround times. So we're ensuring we are adhering to that. We look at trends in you know adverse determinations if a provider group has a you know an end toward amount of denials then we started our own at a provider education team that's really looking at those trends going to the doctor working with their offices to educate them about you know what what's required in a prior authorization what kind of clinical needs to be submitted. What's the timeline to submit it. And all those types of things to further help embrace that partnership. 

DAN: So what could a doctor's office do to make that process easier. So are there some issues that maybe could be solved within a physician's office that would make the process easier. 

LESLIE: So I think one of the primary problems or issues that we see are is that physicians don't submit a complete request so information is left off from the request. For example they’re reference in the medical records an MRI being performed but they don't include the results of that MRI in the actual prior authorization. So I think if the provider is able to submit a complete request with all the information, initially that will help to streamline the process and ensure you know a turnaround time like Alyce was saying. 

DAN: Let me ask you one last question related to that.  So let's say for instance that the prior authorization is denied is at the end of the story with the prior authorization 

LESLIE: In Texas the provider is allowed the option of a peer to peer where he can speak with one of our clinicians whether it's a physician or behavioral health specialist or a physical therapist. So that's the first option. So there is that option for a peer to peer and sometimes in those peer to peer conversations we do get additional information which can lead to approval of the prior..  

DAN: Like that MRI result might be discussed.  

LESLIE: Correct. The next option if the peer to peer appears to uphold the initial denial then the provider does have the option of appeal. And in those particular cases it can actually go on to a specialty match reviewer. So if it was a neurosurgeon then the appeal would be reviewed by a neurosurgeon if requested  

DAN: And does that neurosurgeon work for the health plan. 

LESLIE: Not always. Sometimes we do have specialists here at the health plan that work in appeals and sometimes they're sent out to external reviewers that are specialists. 

ROSS: If I could just mention a couple of statistics, Dr. McCoy, because you were talking about what could doctors do to help expedite this process. I think there's some data out there that shows that the rise of electronic medical records has really helped with that the American Medical Association found that physicians who started using electronic prior authorizations were actually able to save seventeen hundred dollars a year. Remember I mentioned earlier that they said it cost them about two to three thousand so they can get they can return half of that savings by using electronic medical records. Also Prime therapeutics who is the pharmacy benefit manager for Blue Cross and Blue Shield of Texas show that there was a 90 percent reduction in insurance response time per doctors who are using electronic prior authorization. So I think that that that makes a big difference. So Dr. Weisberg let me ask you what has our claims data revealed about prior authorizations. 

LESLIE: So fortunately we do review trends in claims data and we work with our partners in health care management, once we see these trends so if we identify an increase in services that are considered experimental investigational and unproven that maybe do not have a prior authorization. Again we'll speak with individuals like Alyce to see if we can work with them to implement the prior authorization. We also to counter that if we find that certain services are approved on a regular basis. So the majority of the prior authorizations for a particular service are always approved. Then again we would meet with our counterparts in health care management and say we may want to remove the prior authorization from this particular service.  

ALYCE: That's correct. We make informed decisions based on the data. 

ROSS: I would be remiss if I didn't acknowledge that in January of 2018 Blue Cross and Blue Shield of partnered with several industry leading associations, the American Medical Association, the American Hospital Association, America's Health Insurance Plans Medical Group Management Association and the American Pharmacists Association to work on standardizing prior authorization. So all of these entities within the health care continuum recognize that there is a value presumably if they're all working on this that there is some sort of value associated with prior authorizations but it's how we go about doing it that needs to be addressed. So they identified five different things that that everyone within the health care continuum should do to improve the process. One of them is reduce the number of health care professionals subject to prior authorization requirements, regularly review the services and medications, improve channels of communications protect continuity of care for patients and accelerate industry adoption. So you know that's me that says that we are moving in the right direction. I'm wondering if Dr. Weisberg and Alyce, if you could give us an example of how prior authorizations have had a positive impact on a member or a patient. 

ALYCE: We had one member that had cystic fibrosis which is a disease that affects their lungs and the member was having home health come out to do chest compression to loosen the mucus from their lungs so they wouldn't have a hospital admission form for pneumonia. So anyway the members benefit only allowed for 25 visits for the home health. So the request for additional visits was denied based on the benefit. What we did is work with that physician to identify an alternate for the number and ended up identifying a you know compression vest that the member could wear you know at night for so many you know 30 minutes or so and twice a day. So that member could help you know have a another alternative rather than having a home health worker come out there. So it was a very positive outcome for the member long term for efficacy and for cost effectiveness. 

DAN: Well this has been a great conversation. So thanks for shedding some light on a pretty complicated subject like prior authorizations. Thanks for being here today.  

ALYCE: Thank you.  

DAN: Thanks for joining us for this edition of Blue Promise. 


SIGN IN to share your comments or REGISTER today to become a Connect member.