Slight majority opposes prior auths, according to poll

YARMOUTH, Maine – Prior authorizations have their uses, but they also create a heavy burden with no guarantee of payment, say 58% of respondents to a recent HME Newspoll. 

“Prior authorization is fine if the insurance plan honors their end of the agreement,” wrote one respondent. “To do all the work to obtain the PA only to receive a denial is very frustrating. Even more frustrating is to have the plan tell you that prior authorization is not a guarantee of payment.” 

Prior auths are at the top of the news, following decisions by UnitedHealthcare, Cigna and other payers to eliminate prior authorization requirements for a good chunk of product codes in response to pressure from Congress and government agencies and lobbying by the American Medical Association. 

For 42% of respondents, however, prior auths provide a safety net of sorts, they say. 

“Prior authorizations help to ensure that payer documentation requirements are met prior to dispensing, making post-payment audits more likely to favor the provider,” wrote Garry Nichols, director of operations, Taylor Drug. “Administrative burdens could be reduced by implementing CMNs that are considered sufficient to meet documentation requirements.” 

Having consistent guidelines and eliminating unhelpful bureaucracy would also help reduce the load on providers, say respondents. 

“PAs are time suckers,” wrote one respondent. “Many commercial payers have different requirements depending on the state. Trying to get that information and being on hold and transferred multiple times is unbelievably frustrating.” 

Having commercial payers require prior auths for the same codes as Medicare would also help, say 69% of respondents. 

“There needs to be uniformity across all insurances,” wrote one respondent. “Commercial payers refer to CMS but don't adhere to the same criteria.” 

Despite their drawbacks, there are products for which prior authorizations make sense, especially for costly and complex equipment, say about 73% of respondents. 

“Prior authorizations play an important role in the complex rehab world,” said Chris Smythe, president, Tycon Medical Systems. “Providers need to know that an expensive, customized power wheelchair is going to be covered before purchasing and providing it to a patient. Without a prior authorization, providers take on a significant financial risk.” 

At the end of the day, it’s time for an overhaul of the prior authorization system and providers should get a seat at the table, respondents say. 

“(We need to set) clear expectations for prior auths and (get) input from DME in the development of prior auths,” wrote one respondent. “We (should) all share the same goal of reduction in administrative burden and appropriate use of product. Commercial, Medicare and Medicaid (should) align on prior auths when possible.”