One way health plans seek to control costs is with prior authorization. Sometimes called precertification or prior approval, this process requires that health-care providers obtain approval before a service is delivered to the patient in order to qualify for payment coverage.
Prior authorization is needed to ensure coverage of certain drugs or for step therapy. With step therapy, patients must start with the preferred drug. Depending on the response to the drug, permission must be granted by the insurer to move on to the next agent. Certain services, devices, and surgeries also require prior authorization.
To facilitate prior authorization, practices must have an infrastructure in place that tasks staff with making requests to the insurer. This boils down to a lot of time on the phone or navigating online portals. In addition, according to the 2016 American Medical Association Physician Survey, a single prior authorization request costs a practice approximately $100 in staff time and resources.
“In the ophthalmic space, and predominantly the retina space, we see patients with acute problems,” says George Williams, MD, past president of the AAO, and Department of Ophthalmology chair and director of the Beaumont Eye Institute at Beaumont Health in Royal Oak, MI. “Even if a patient needs immediate treatment, we still have to go through the process of calling the insurance provider. Always problematic at multiple levels, the burden of prior authorization has been amplified in the COVID-19 era.”
While practices were shuttered to all but emergent needs, many practices used a skeleton crew, which left little time to make prior authorization phone calls. Many eye-care providers are back to a “new normal” routine but are faced with a backlog of patients, scheduling challenges, and, in many cases, reduced staff. Having to assign an employee — or in some cases the physician — to navigate the prior authorization process has resulted in frustration.
“We simply do not have the time for these phone calls and their notoriously long hold times,” Dr. Williams says. “With COVID-19, insurance companies have many of their people working from home or not working at all, further adding to extensive delays.”
Eliminating surgeons' choice
The difficulty of being able to reach an insurance provider to approve the use of Lucentis (ranibizumab, Genentech) or Eylea (aflibercept, Regeneron), for example, may force retina surgeons to use the cheaper (and shorter-acting, in Dr. Williams' experience) Avastin (bevacizumab, Genentech) even when it's not the surgeon's first choice.
With step therapy, a patient has to “fail” the preferred treatment before the next agent can be used. “Does that mean the patient doesn’t get better?” Dr. Williams says. “Does that mean the patient has to lose vision? We are aware of one plan that requires the patient to lose three lines of vision before it is considered a failure.”
Dr. Williams says this concern has exploded under the Medicare Advantage plans. “Prior to 2019, Medicare Advantage could not deny its beneficiaries services that were available through Medicare fee-for-service. Effective January 2019, that changed, and now the vast majority of Medicare Advantage plans require that we start with Avastin,” which takes away the ability to individualize treatment.
Hurdles with other injectables
According to Mark L. Mazow, MD, oculoplastic surgeon at Eye Plastic Surgery Associates in Dallas, the prior authorization process also applies to injections used for blepharospasm and hemifacial spasm.
“We use one of three similar, but still distinct, botulinum toxin agents for this condition. Medicare Advantage and some commercial carriers make obtaining access to this treatment very difficult for patients,” says Dr. Mazow, president of the Texas Ophthalmological Association and spokesperson for the AAO. “It can take a month or sometimes longer to receive authorization to be granted approval for the medicine, which we then have to order from a specialty pharmacy.”
Surgeons can even have trouble obtaining some commonly used antibiotics. “Some plans will require prior authorization that can take 3 or 4 days,” Dr. Mazow says. “Meanwhile, the patient has an infection and can’t get the appropriate treatment.”
Some patients and doctors will just give up and circumvent the insurer, Dr. Mazow says. “I’ve had to tell patients, ‘I can’t get it approved, there’s no one there to talk to, but you need to have this antibiotic.’ Using the GoodRx app on my electronic prescribing, I will find out where the patient can get the drug for the lowest price. Some will just go ahead and pay for it, but others cannot afford it.”
Jumping through hoops for surgery
Corneal transplants and other sight-saving surgeries are not spared prior authorization frustration and delays. Ashlie Barefoot Malone, MBA, JD, COE, practice administrator at Carolina Cataract & Laser Center, says the surgery scheduler in her practice is forced to plan her day around obtaining prior authorization.
“As an administrator, I can't efficiently staff for this,” she says. “We have tried different scenarios. Our scheduler, Anna Harvey, is amazing at juggling prior authorization and she's very efficient, but you can't pay someone to just to sit on hold with Blue Cross for an hour and a half.”
Ms. Barefoot Malone noted that corneal surgeries are physician-driven, medically necessary procedures, and they rarely get denied. So really, what is the point of this, she asks? “If insurance companies truly were trying to make sure that procedures are being appropriately authorized, then more of them would be denied. They are just creating an administrative burden on offices for something they are going to approve anyway.”
Cataract surgeons are now encountering new guidelines due to COVID-19 issued by WellMed, an insurance company that carries a Medicare Advantage product in Texas and Florida. “They have begun requiring a different level of prior authorization for cataract surgery,” Dr. Mazow says. “With this rule, the patient's primary care physician weighs in with his or her perception of the patient’s risk for getting COVID, which then factors into whether or not authorization for cataract surgery is granted.”
At Carolina Cataract & Laser, one staff member is assigned to tackle prior authorization for all surgeons. To make it as streamlined as possible, they have set up a cheat sheet that lists the pertinent codes for the procedures as a reference point, as well as the top insurance plans. Ms. Barefoot Malone says it is a simple, helpful tool because there is a high opportunity for human error with the process.
Dr. Williams says that his practice also uses a grid that organizes the insurance plans and their processes for reference.
When it comes to tiered medications or step therapy, the lack of prior authorization can result in pharmacy callbacks and surprise prescription swaps. These callbacks from the pharmacy are also time consuming. Some advice for tackling this issue includes having a dedicated phone line to reduce interruption to the day's flow and being more proactive in identifying what medications might be problematic. Electronic medical records can also help physicians to understand what a patient's insurance plan covers. In addition, practices can be proactive and contact the pharmacy to let them know physicians' preferences and why a specific medication was prescribed. Some drug manufacturers provide discount cards to patients to cover the difference between brand and generic medications, for example, and some specialty “boutique” pharmacies have prior authorization teams to help save time with the process.
Trying to change the system
The AAO is part of the Regulatory Relief Coalition, a group of 13 national physician specialty organizations advocating for a reduction in Medicare program regulatory burdens to protect patients' timely access to care. H.R. 3107, the Improving Seniors’ Timely Access to Care Act of 2019, has been introduced, and the AAO reported that the legislation now has the backing of half of the U.S. House of Representatives co-sponsoring the bipartisan legislation. The legislation would help protect patients from unnecessary delays by streamlining and standardizing prior authorization under the Medicare Advantage program.
“In addition, it would prevent secondary denials — something that should be illegal. We also need to bring this system into the 21st century with a standard online process, not phone calls with interminable hold times and, believe it or not, faxes confirming authorization,” Dr. Williams says.
Dr. Mazow also emphasizes the need for advocacy and awareness. “We need to let our state legislators and members of Congress know what we are dealing with.” Meanwhile, the AAO continues to solicit stories from its membership about not being able to get needed treatment for patients, to impress upon the programs how critical this issue is and the negative impact prior authorization has on patient care. OP