The avalanche of prior authorizations

[pebblebeach, BSN, RN]

Hi clinic RNs,

I was previously a bedside nurse who transitioned to clinic life. We deal with a lot of patients on biologics (humira, etc.). The biggest learning curve for me coming from bedside is the barrage of insurance denials, prior authorization appeals, and of course the multiple phone transfers, being on hold, faxes lost and re-sent, and follow-up involved. The RNs who have worked there for years have said that 2019 has been the worst year yet in terms of pushback from insurance, and has taken up more of their time now more than ever. It takes so long to initiate and complete these requests that other clinical tasks are getting ignored.

If you deal with a lot of this at your clinic, how is it delegated? I've heard of clinics hiring LPNs or RNs specifically to work on specialty med insurance/PAs, but that's not in the budget.

Curious to know what your practice has tried - even if it failed. Thanks.

[Colette RN]

I was hoping to see more responses here since I have also experienced the prior auth avalanche! Our clinic did a time study early last fall and the hours spent supported developing a prior auth. dept. (a few people) that would handle medication prior authorizations. In theory, having a few knowledgeable individuals who would gain expertise with specific drugs and insurance plans could increase efficiency and ease the burden on nursing staff. Unfortunately this has not materialized. Also, my experience with CoverMyMeds has been fair at best. At one time I started a spreadsheet for specific payers/insurance companies with direct links to the websites having needed forms and helpful phone numbers. This worked better for Medicaid and a local Sanford plan that I found out the hard way weren't supported by CoverMyMeds. In all, the whole prior authorization process makes me long for price transparency and less administrative expense!

[Lemon Bars]

I have been working as an RN in a primary care clinic for nine months, and my experience with prior-authorization requirements is similar. This really highlights the problem with our third party payer system. Patients want unlimited access to expensive medications, specialists and imaging because they don't pay the cost of these things. Insurance companies make more money when they deny services, so they have thrown up a wall of red tape. Medical professionals are caught in the middle. Many times we don't even know that a medication wasn't covered until a patient calls weeks later saying that they never got the medication prescribed, and now they can't breathe, can't sleep, their blood pressure is out of control, or they end up in the hospital. I'm really surprised there aren't more lawsuits about this - but of course patients can't afford lawyers so they are just stuck, I guess.

My clinic has a department for referrals and insurance issues. When I started nine months ago there were three administrative people in that department (none of them had formal nursing or healthcare training). One staff member in that department was fired, another left on maternity leave, another got hired and then got fired. So we have one full-time staff member digging through chart notes and trying to process referrals and prior authorizations. Our office manager sometimes helps, when she has time. I do peer-to-peer reviews with insurance companies, which is successful about 40% of the time once the request finally gets to that step, often after multiple denials and resubmissions.

As you can imagine, we are several weeks behind on prior authorizations - and that is only counting the first submission of the request. Patients are waiting months or even more than a year to get an MRI, or they just never get one. To be fair, though, we have patients who refuse to do physical therapy, refuse to get labs done, no show at specialist appointments, and otherwise don't follow through with the steps required in the plan of care.

This situation has affected my personal medical care as well (through a different medical clinic). A change of insurance caused the need for a prior authorization on one of my own personal medications. Despite multiple phone calls and a letter from me, that medical clinic was not capable of going through my records and providing my new insurance company with documentation that I had already tried the alternative medications suggested by my new insurance company. I now get by without this medication, but my quality of life was higher when I was on the medication.

I have some ideas on how to improve the situation, but none of them are practical and easy to implement at the clinic level. One tremendous improvement would be to partially or fully integrate the computer systems of all medical facilities, pharmacies and insurance companies everywhere. I refuse to believe that this is impossible, though it may require new federal legislation to bring everyone to the table. Another improvement/solution might be integrated healthcare systems such as Kaiser Permanante, which mitigates the negative effect of our third party payer system. Or if we could put a pharmacy tech in every clinic, someone who could run medications through a payment system and come up with alternatives, that might be helpful. If insurance companies are going to continue to make things difficult, maybe insurance companies should be legally required to cover the cost of staffing for prior authorization departments.

I am on the computer and phone most of the day dealing with medication refills, insurance issues, and managing those unbelievably time-consuming and stressful controlled substance prescription issues. I spend more time doing this than doing real nursing activities like triage, education and medical follow up. Honestly, I'm looking for another job, perhaps in home health or a specialty office. I can't go back to working in unsafe, understaffed hospitals. It is early in my nursing career and I'm seeing a long and rough road ahead, for both patients and medical professionals.

[Colette RN]

Check out this interesting article (and there are more if you do a quick internet search) on fastPATH.

https://ehrintelligence.com/news/ahip-program-points-to-health-it-ehrs-for-prior-authorization

It is a proposed platform that has the potential to standardize the prior auth process across insurance providers. Too bad they are only trialing it with 7 plans. Though the total number of members are high, I have only noticed a scattered population that is insured by Anthem, Wellcare, and Cigna. I am not in CA or FL. At least the problem is widely recognized and efforts are being made. Thoughts?

[lpn164]

I am so thankful to no longer have to do referrals as my current employer has a dedicated person to do this and we also have a concierge service now as well. However I have done my fair share for sure. The biggest problem that I witnessed (and learned the hard way myself) is that often the nurses call and waste so much time on hold or getting to the right place and they are missing information. You must do the research - you have to pretend you are the patient and you need to know why you need this exam or medicine and why you cannot do an alternative - once you can investigate properly and provide proof with the right answers / codes that are needed it is SO much easier. I also always kept a cheat sheet for all the insurances #'s the option #'s etc. Before long I never got denials on procedures (some meds we had to do trials). I maybe had to do a peer to peer 5 x a year max. Hope this helps and hopefully your office will realize how much good work and patient care could replace this by hiring someone for this. Good Luck!

[pebblebeach, BSN, RN]

Update since my original post: I left this job - for a few reasons, but a huge reason was that they DID end up hiring someone specifically for this task to handle prior auths -  an experienced LPN who was excellent - patients were getting PAs/appeals done in a timely fashion (and therefore, their meds on time, most importantly) I constantly echoed my praise for this person and how valued they were to the RNs and patients overall care - unfortunately, management didn't listen, the LPN quit for a better opportunity - and they didn't replace her. The PA avalanche piled back up in DAYS after LPN left. I immediately started looking for other jobs. IMO, It is now ESSENTIAL to designate a separate position for this need now; the RNs do not have the time - and frankly, it's a waste of a good RN to have them sitting on hold w/ BCBS for 2 hours when they could be... I don't know, giving vaccines, educating patients on their meds, triaging pts on phone whether to go to ER or not during a pandemic, etc. etc. 
It's a tremendous urgent need that is just going to keep growing, and clinic management needs to recognize that need, or people will get fed up and leave.