More medical services now require prior authorizations, according to physicians

In a recent survey, 84% of providers reported the number of medical services that require prior authorization has increased.

And 62% of providers reported that they do not have the technology to evaluate whether a prior authorization is required for a medical service, diagnostic test or medication without initiating a prior authorization request, according to a survey by the nonprofit WEDI.

The survey highlighted technology limitations, increased prior authorization requirements and the desire for mandated standards, said Jay Eisenstock, chair of the WEDI board of directors, who presented the results during testimony late last year before the Department of Health and Human Services (HHS) National Committee on Vital and Health Statistics.

In terms of the volume of prior authorizations, only 55% of vendors and 42% of payers reported the number of medical services that require a prior authorization has increased, much less than providers themselves.

RELATED: MGMA19—No progress to fix prior authorization, as practice leaders say it's gotten worse

The survey also looked at the difficulty of determining whether a prior authorization is required. Only 45% of vendors reported having technology to evaluate whether prior authorization is required without initiating a request to insurers.

A sub-work group of WEDI, which studies the use of health IT to create efficiencies in healthcare information exchange and advises HHS, conducted the survey last August to analyze the current prior authorization process. The group plans to use the results to develop guiding principles to support increased automation and standardization.

Prior authorization is a major headache for physician practices, and a Medical Group Management Association survey last year found practice leaders said it was the most burdensome regulatory issue they face.

The survey received responses from 65 providers, 31 payers and 31 vendors. Other results included:

  • Web portals (27%) and payer websites (26%) were the most common methods providers said they used the majority of the time to determine prior authorization requirements.
  • Some 33% of providers and 37% of payers reported that a web portal was the most used method to initiate the majority of prior authorization requests.
  • A majority of providers (67%) said they find it difficult to determine which method to use to submit prior authorization requests to payers.

RELATED: Insurers aim to get physicians to incorporate electronic processes for prior authorization

“While the industry has made great progress, this survey shows how much more work there is to be done to clarify and standardize prior authorization workflows,” said Eisenstock. The topic was a key point of discussion during a recent Health Information Technology Advisory Committee meeting with Office of the National Coordinator for Health IT officials, he said.

Results of the survey were also presented during a December briefing on Capitol Hill, where a panel of WEDI experts addressed policymakers and federal agencies to announce emerging automation trends that can reduce prior authorization challenges, lower costs and improve patient care.

A separate study released last week by CAQH found the cost of  prior authorization requirements on physician practices has continued to increase—up 60% in 2019 to manually generate a request to insurers. CAQH said the medical industry could see potential annual savings of $454 million by transitioning to electronic prior authorizations.

Infographic showing results of survey