Bridging the Gaps in Prior Authorization: Challenges, Solutions, and Collaboration for Better Patient Care

Featuring David J. Sand, MD, MBA, chief medical officer at ZeOMega

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David Sand, MD, MBA: Hello, everyone. I'm David Sand. I'm the chief medical officer at ZeOmega. We provide the industry platform for healthcare enterprise management. My journey to this point has included solo private practice in ear, nose, and throat, head and neck surgeon, followed by nearly 25 years of experience on the executive side of health care as chief medical officer of the former Ohio QIO, a national program integrity organization, and multiple health plans, from startups to turn arounds to large and well-established organizations, including the recent engagement with Anthem Blue Cross Blue Shield as their chief medical officer for their national Medicare Advantage business. It's a pleasure to be here.

What are the most prominent challenges with traditional prior authorization processes for providers and payers?

Dr Sand: I'll start off by saying, first of all, nobody likes it. The providers don't like it, the payers don't like it; it's tedious, it's fraught with regulatory pitfalls, and it's expensive. So from the standpoint of understanding a system that, up until now, has been relatively nontransparent in terms of expectations, and from the provider standpoint, a feeling of having to jump through hoops, having their expertise questioned, it's a system and a process that gets a lot of bad press.

Do you feel that there’s an opportunity to input payer-friendly language that the provider may not be providing, or vice versa, to bridge that gap?

Dr Sand: Some of the topics that we're going to go into in a little bit touch on that subject. The most important part, and also very pertinent to your readers and listeners, is the fact that the system should be based, and is based, on best practice and an evidence basis. There really should not be a lot of doubt regarding what the evidence is in the literature. Plans do not arbitrarily impose their logic or their requirements on these services, and they cannot be more restrictive than traditional Medicare. So I think that if both sides are intellectually honest, the expectations should be fairly reasonable and well understood.

It impacts patients' care, because when there is that disconnect, it's hard to get the patient the treatment that they want if there are those obstacles that you mentioned earlier. So can you discuss some of those obstacles or challenges in patient care, particularly when it comes to delaying their necessary treatments?

Dr Sand: While the concept is becoming better understood, the concept of medical necessity doesn't mean that treatment is not necessary, but that the particular service that is requested may not be the most appropriate one for an individual in that circumstance at that time.

Your question is interesting in that you framed it in terms of what the patient wants and expects. It may not necessarily be what the evidence shows is best for that individual. Additionally, many patients don't understand that when they are with their provider, sitting in the office, and the provider says that she is going to order a particular service for them, the request may not go in exactly at that time. In fact, it may not go in until several days later. What seems like a delay in the process is simply a resource issue, perhaps on the provider's side. Additionally, the requirements for information to substantiate the request, again, given the patient's unique circumstances, may not always be included in the initial request in the submission. This is typically the most common cause for holding up the profit, for resulting delays, and the back and forth that goes on between payer and provider. It's typically very frustrating.

When it comes to delaying care, I think we need to be careful in that discussion as well. Medicare Advantage plans are not allowed to deny emergency care. They're not allowed to require prior authorization for emergency care. If it's an emergency, the provider has carte blanche, essentially, to go forward with the treatment. If something is urgent and, to use the terms from the Medicare managed care manual, delaying or denying the service may result in harm to the individual or a delay in their ability to recover, then providers have the opportunity to request a procedure as an expedited or urgent request, in which case the time allotted to plan for a response is significantly reduced.

When they're pushing forward to have that type of emergency care, does that affect costs or payments from the patient? Is there coverage associated with that if the provider pushes through and marks it as something that can negatively impact a patient if not performed?

Dr Sand: Generally speaking, I would say most providers wouldn't request it if they didn't feel the absence of the service would negatively affect the individual. In that respect, the patient and the provider would consider the care necessary. The urgency of the care does not impact copays, coinsurance, or ultimate coverage decisions.

Focusing a bit on costs and coverage, in the scenario where it may not be a dire situation, how can payers and providers collaborate to balance cost containment with ensuring optimal treatment access in changing, for example, an MA payment structure?

Dr Sand: It's such a pertinent question because health care resources are not infinite, and we do need to be good financial stewards of the system, as well as hopefully endeavor to provide high-quality, high-value care.

If we take a look at making sure that the care that is requested and the care that is provided is high quality and, going back to a phrase that I coined in 2005, medically necessary care is really the right care for the right person at the right time and the right amount in the right setting. If we stick to those principles, I think that we have a very good start at being good stewards of the system.

Additionally, there are terrific resources available to providers and payers in the public domain to guide us in terms of high-value care. Certainly, the peer-reviewed published literature, the contributions that your organization makes to that, and other organizations, such as the American Board of Internal Medicine, that publishes the Choosing Wisely guidelines. These are available to providers, to patients, and payers, and really provide a great structure when we want to talk about providing high-value care.

Given your background in both the clinical practice and the health plan leadership, how do you see electronic prior authorization systems impacting efficiency and patient care in Medicare Advantage plans?

Dr Sand: I'm excited about it. Once we get over the initial hurdles, it's going to be fantastic. The ability for a provider to submit a request while the patient is sitting in the exam room and receive an almost instantaneous response is really going to remove so much of the abrasion of the prior authorization process.

One of the biggest reasons why prior authorization requests aren't approved, as I mentioned earlier, is that the documentation is not submitted initially to substantiate the request. In fact, when we take a look at adverse determinations that are appealed, about 83% of them are overturned, and that happens because the required documentation is finally submitted. When we look at electronic prior authorization and the requirements of the new rule that was recently released, 0057 by Centers for Medicare and Medicaid Services (CMS), and the ability for electronic prior authorization systems to literally reach into the electronic health record and extract the necessary information to substantiate the request, I think that it is really going to revolutionize this entire process and remove so much frustration.

A lot of providers are tasked with doing so much administrative work, and it's causing delays throughout the practice. Do you feel that this too can help reduce that burden on providers and get these things through and approved faster?

Dr Sand: You're absolutely correct. Years ago, when I was still in practice, I did a time study on myself, and I was spending probably 60% of my time in nonpatient-related activities. It is burdensome, and it's expensive. It's a great source of friction.

Are there successful models or partnerships you've observed where payers and providers effectively collaborate to overcome any prior authorization challenges?

Dr Sand: I think there are. I don't know that they're necessarily widespread, but the adoption of electronic prior authorization is certainly going to be one of them.

We're seeing progress in clinically integrated networks, particularly provider-owned plans where there tends to be aligned incentives and a general understanding of what the expectations are overall for the system to provide high-quality care. There are opportunities as well for common sense, quite frankly, in the system. As I've looked and reflect on my own experience as chief medical officer at a number of health plans, allowing some flexibility—not just kicking the can down the road to make sure that every box is checked in the prior authorization checklist, but to understand what's reasonable, what the individual situation is and to, as I have in the past, give guidelines to the utilization management nurses who are not allowed to deny anything but can approve. Expanding their discretion in approving some of these things rather than just kicking the can down the road is a great opportunity.

Many states are now moving forward with the concept of gold carding for physicians who basically are doing it right, who are following the clinical pathways, who are aware of the best-practice evidence in the literature. Whether they're following the Choosing Wisely guidelines—and I'm not necessarily advocating for the American Board of Internal Medicine, but they're good public domain guidelines—or, as the American Academy of Family Physicians said back in 2003, understanding the evidence basis. If you submit those types of requests that are based in the evidence then, again, I think that you should be recognized and, in some cases, given a path on requiring prior authorization, because if you're doing it right, I don't think that removing the prior authorization requirement is going to cause you to do it wrong.

Generally, physicians who are intellectually and academically honest will behave in that manner, whether or not there's a prior authorization requirement. So I think the gold carding progress that we're seeing in a number of states and, frankly, in a number of payer organizations, can also go a long way to easing the stress.

Do you believe that things are slowly moving in the right direction?

Dr Sand: I think they are. A number of years ago, when I was at Anthem, I provided testimony to Congress and to the House Ways and Means Committee on utilization management. They wanted to know why we did it, because it was viewed as a negative. I don't think utilization management will ever go away. We have a responsibility to be good financial stewards of the resources. We need to make sure that high-value care is being provided, and, in instances where it's not, to be able to monitor, measure, and take appropriate action.

Unnecessary care, redundant care, care that leads to potentially false-positive results, which then lead to additional invasive procedures—we need to be cognizant and be aware that that does happen. Utilization management does provide a method of assuring high-quality, high-value care and identifying opportunities where intervention can occur to improve behavior and improve the care our patients get.

What's one key takeaway you hope the audience gains from this interview?

Dr Sand: I think there's a lack of understanding of the utilization management process on everyone's part, and I would love to see the temperature of the rhetoric ratcheted down a bit. As I said, it's unlikely that it will ever go away; understanding that it is a highly regulated aspect of Medicare Advantage, that plans' payers do not have a lot of discretion in what they ask and what they require, and in the ways that they have to perform.

Plans that don't perform according to the regulations risk the loss of their contract with the CMS, and the plan, frankly, will go out of business. There are a lot of requirements for providers to understand that, to a large extent, payers' hands are tied by these regulations, whether it's in turnaround time, required evidence, or the types of determinations that they issue and the services that they cover and don't cover.

It is illegal for plans to cover things that Medicare says they cannot cover. Just as they can experience jeopardy from denying appropriate care, they can experience jeopardy from approving care that Medicare says they should not. It's a highly regulated area of health care. Understanding on the parts of all the stakeholders—including patients as well as providers and payers—can really go a long way to lowering the temperature of the discussion and hopefully reducing the abrasion.