Prior Authorizations: Not Only a Thorn in the Physician’s Paw, but Potentially Dangerous

The Prior Authorization (PA) process has become so arduous that practice management experts offer tips that include performing a cost-benefit analysis of the top payers in the practice to determine how many PAs they required over the past year and consider dropping those who create the most administrative waste. The experts also recommend physicians learn which drugs are covered on each of the plans they are contracted through and to write for generic drugs whenever possible — great advice, but obviously provided by someone who does not practice clinical medicine!

Over the past three years, there has been a significant increase in the number of PAs required by insurance carriers, even for generic medications that have been available for over a decade. Often, these medications are available for a fraction of the cost by avoiding insurance altogether and paying cash. Patients have the option of using free consumer applications, such as GoodRX, using discounts offered by Wal-Mart without coupons or memberships, or purchasing a discount membership directly through many pharmacies like the one Kroger offers where a $36 annual membership fee provides a discount on many popular generic prescriptions, some of which are free with the membership.

Current data demonstrates the PA process is not only burdensome for the physician and medical staff but may also lead to poor outcomes for patients through delays in approval or insurance coverage denials. To improve care and patient safety, all physicians should be aware of alternatives for patients in obtaining necessary medications and share these with their patients. Patients should also be mindful that sometimes it is more cost effective and expedient to leave their insurance card at home and pay cash for many of their prescriptions.

I guess the practice management experts forget to mention that? But their slides were sure pretty.

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Cynthia R Stuart DO

Dr. Stuart is Board Certified in Family Medicine. Originally from Georgia, she spent most of her youth in Miami, Florida and has been a Texas resident since the early 1990s. She attended UNTHSC-Fort Worth and completed her residency at UTSW/Methodist Hospital System where she was Chief Resident in her senior year. She is an Associate Professor at UTSW and UNTHSC, participating as a preceptor for medical students and residents. She completed a two-year course at SMU Cox School of Business in Advanced Leadership that enables her to advocate for quality health care providers and local public health programs in her community. She is the head of the Credentials Committee, sits on the Medical Executive Committee and the Ethics Committee at Baylor Scott and White Hospital of Carrollton. She has appeared on numerous news and radio programs to educate the public about various health topics. Dr. Stuart has managed her private practice in Carrollton since 2005 and is now a Direct Primary Care Physician. 

  6 comments for “Prior Authorizations: Not Only a Thorn in the Physician’s Paw, but Potentially Dangerous

  1. Randy
    May 14, 2019 at 8:52 am

    “all physicians should be aware of alternatives for patients in obtaining necessary medications and share these with their patients”

    I agree with this. it sucks because we all have better things to do, but part of our job is to work with the system as it is for the benefit of the patients.

    You’d think the pharmacists would do this but often they don’t, especially with the bigger chain pharmacies. I’ve often wondered about the ethics of a pharmacist letting a patient walk away without the medication they need, while knowing there are discounts or affordable alternatives.

    I also wonder about how it’s in the best interests of insurance companies to spend administrative time and money denying cheap generic medications.

    • RSW
      May 14, 2019 at 10:06 am

      As long as we spend our time and effort shielding our patients from the abuses of their crappy insurers, things will only get worse.

  2. RSW
    May 14, 2019 at 8:11 am

    “To improve care and patient safety, all physicians should be aware of alternatives for patients in obtaining necessary medications and share these with their patients.”

    Nope.

    No room on my plate.

  3. James Tinsley
    May 14, 2019 at 7:04 am

    The AMA and AAFP helped give birth to this system with our money. Now they want our money to fix it. They are like gun dealers selling to both sides of a war. It’s a great job for them. They get paid no matter how bad a job they do.

    • PW
      May 14, 2019 at 9:05 am

      They are losing members now because of these shenanigans.

      • Jennifer Hollywood
        May 14, 2019 at 10:33 am

        I left the AAFP this year. I feel like they no longer have family physicians best interests as their goal. They willingly went along with MACRA and MIPS and MU. And all the while made money on educational content to help us meet those goals.

        Per the article, I will direct patients to goodrx.com. You are right, RSW, that I have no more room on my plate. But if a patient can get their medicine for a good price AND I don’t have to do a pre-auth for that to happen, then it might actually save me some time. My office staff can redirect them to the site and we have free rx cards up front for the patients to take with them. We had to start this when we started getting inundated by preauths for generic medicines which cost under $20 for a three month supply. Plus, my male patients like getting their generic viagra for less than $1 per pill.

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