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The avalanche of prior authorizations

Ambulatory   (289 Views | 1 Replies)

pebblebeach has 3 years experience as a BSN, RN and specializes in Orthopedics.

1 Article; 2,209 Profile Views; 69 Posts

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.

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Colette RN specializes in Varied.

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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!

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