I hate prior auths.
I understand that health insurance companies do not want providers to be ordering medications, diagnostic tests (labs, imaging, etc.), or completing procedures that are not medically necessary, but prior authorizations are frustrating.
Why can’t I use my medical knowledge to order a CT scan for a patient with abdominal pain? Or send a prescription for a medication that will significantly reduce a patient’s A1C (ultimately saving the health insurance money)?
The frustrating part is the time and energy I or my support staff have to spend completing prior auths. Not to mention, the delay in care or lack of appropriate care for the patient.
And prior authorizations are on the rise in this modern healthcare system. It seems like getting approval (and denials) from health insurance companies is becoming more and more common. In this article, I share my personal experience and frustrations with prior auths (please tell me I’m not alone with these frustrations!).
What are prior authorizations?
Before we get into the frustrations of prior authorizations as a nurse practitioner, lets first look at what prior auths entail.
Prior auths are a way for health insurance companies to determine medical necessity and appropriateness of a prescribed medication, diagnostic test, or procedure.
Prior auths are a way to ensure nurse practitioners are ordering medically appropriate tests and treatment. When completing a prior auth, health insurance companies will determine if they will cover the medication, test, or procedure. The health insurance company may provide feedback for preferred medications or reasons why it may not be medically necessary to complete a procedure or test.
Completing a prior authorization is different in many practice settings. For example, in the ER setting, prior auths are not required. Whereas in the outpatient and clinic setting, staff spends a lot of time completing prior auths.
My frustrations of prior auths.
Sometimes support staff (RN, LPN, MA, prior auth experts, etc.) helps complete and follow up on these prior auths. However, if your practice setting is like the clinic I work in, adequate staffing has become an issue. We have struggled with finding and hiring enough LPN/MA to help with some of the work. Therefore, a lot of these extra tasks end up falling on my plate (does anyone else experience this too?).
I complete a majority of prior auths for medications. Occasionally I do pre approval and/or peer to peer review for radiology tests but for the most part, we have staff taking care of imaging prior auths. With pharmacological prior auths, I have experienced the frustrations of a denial and completing an appeal process. I have spent hours on the phone with insurance companies, trying to get medications approved. I also have to reassure the patient and explain prior authorizations take time.
Prior authorizations have been so frustrating to me that I decided to try to improve my own process and outlook of the time consuming task. It’s still a work in progress and extremely frustrating at times, but I am working at it! In this two part series, we will take a look at four frustrations of prior authorizations and then look at tips for completing a prior auths.
5 frustrations of prior authorizations
Below are the five frustrations nurse practitioners experience when dealing with prior authorizations. Read through each of these and then comment below what challenges you would add to the list!
Delay in care.
As many nurse practitioners know, prior authorizations can cause a delay in care. For example, if a nurse practitioner prescribed a medication that needed a prior authorization while seeing the patient in clinic on a Tuesday, the determination of the prior auth may not come in until Friday (sometimes later).
A survey completed by The American Medical Association noted that 33% of physicians experienced a prior auth lead to a delay in care that caused a severe adverse event (p.s. we need more surveys about prior auths as nurse practitioners). This is a significant issue that should not be happening. Our patients should not have to experience a delay in care while waiting for pre approval from their health insurance.
Another delay in care may be caused by a lack of time as a nurse practitioner or support staff. It is difficult to complete the necessary paperwork in a timely manner as APRNs are plenty busy!
There are many tasks a nurse practitioner does. For example, it should be a priority to assess, diagnose, and treat the patient. Then the APRN has to document all clinical findings. The nurse practitioner also has to address the EHR inbox: review diagnostic data, address medication refills, review medical documentation, and manage patient messages. This leaves little time to complete prior authorizations!
The craziness of the clinic prevents staff from completing prior auths in a timely manner. The second step is for prior auth to be sent to the patient’s health insurance which again takes some time to complete a review. It may take several days to weeks which causes a delay in care for the patient.
Lack of adequate care.
I feel sorry that the patient is not able to receive the care they deserve. There are so many fantastic treatment options out there, but if the health insurance company does not want to pay for them, the patient does not have access to them. I am not able to prescribe the medications that would benefit the patient because it costs the insurance company too much money.
In this modern healthcare system, it seems like prior authorizations are becoming more and more common. I once had to complete a prior auth to approve insulin needles and glucometer for a Type 1 diabetic! Talk about frustrating! Apparently the insurance company only approves a certain brand of insulin needles and accucheck machine. But why did I have to waste my time to get a Type 1 diabetic the supplies they needed to survive!
And how many times have I had to force a patient to complete 6 weeks of physical therapy (don’t get me wrong, PT provides so many benefits and I am a strong advocate) only to get an MRI approved through the health insurance. In certain cases, we know physical therapy will not help the real issue and following the guidelines of the patient’s health insurance only delays the definitive care.
These strict guidelines cause the patient to suffer. The patient is not entitled to the care they deserve, and it is beyond frustrating.
Time of staff.
Whether it is the nurse practitioner completing prior auths or support staff, it takes a lot of time to complete the prior auth. The provider has to review the diagnoses/indications for the prescribed meds, any past treatment that failed or was not tolerated. Then the provider completes the necessary form and sends it to the patient’s health insurance. The provider must then follow-up to assess determination. If the prior auth is denied, the nurse practitioner/support staff may complete an appeal which again is time consuming.
It may also be necessary to call the insurance company to process the prior auth or clarify information. I have had to do this and usually spend 15-30 minutes of my time on hold/talking with insurance staff. What is most frustrating is when the representative tells you to complete the form online (would have been nice to know from the start).
The survey completed by The American Medical Association reported approximately 14 hours a week are spent by physicians or support time completing prior authorizations. The time it takes staff to complete these prior auths could have been spent on more productive tasks. The support staff could have done better patient education. The nurse practitioner could have seen more patients, bringing in more income. The NP could have finished the chart note so they wouldn’t have to stay late at the office or bring charts home. The nurse practitioner wouldn’t feel burned-out from the added tasks.
The time to complete prior authorizations really puts a strain on the already busy work day for nurse practitioners and support staff.
Lack of work-life balance and nurse practitioner burnout.
As The Burned-out Nurse Practitioner, I am a strong advocate of improving work-life balance as a nurse practitioner. As previously mentioned, prior authorizations are very time consuming for nurse practitioners. When the APRN’s time and energy is drained from completing prior auths, there is a decrease in productivity. This causes the provider to be behind during the work day.
Many NPs stay late at the office or bring their charts home. This disrupts their work-life balance and time with family. This lack of work-life balance is a major cause of nurse practitioner burnout. I have heard this time and time again.
Nurse practitioners doing tasks that could be delegated. Tasks that should not take the time or energy of the provider. Tasks that are becoming more frequent in this modern healthcare system. This is part of the reason nurse practitioner burnout is on a rise.
APRNs should be allowed to leave work at work- physically, mentally, and emotionally. NPs should ensure time for rest and relaxation, for self-care, for energy to do the things that bring us joy. The additional time and energy to complete prior authorizations creates a lack of work-life balance for nurse practitioners.
Imposter syndrome in nurse practitioners.
When a health insurance company denies a prior auth, it can create a sense of imposter syndrome for the nurse practitioners. The NP may have a lack of confidence or second guess their clinical judgment. Maybe they think they should have prescribed a different medication. Or been more thorough with the patient’s physical exam. Maybe the NP questions if they added enough information on the prior auth form and fear they are missing something.
I have definitely felt imposter syndrome and lack of confidence when I have a rejected prior auth. I remember having to do a peer-to-peer review via telephone with a radiologist in order to approve an MRI of the spine. I felt belittled and embarrassed when the radiologist questioned why I didn’t do a thorough musculoskeletal exam. This experience definitely made me feel insecure and like I didn’t know anything.
**I will say, after this negative encounter, I have done better about doing a complete physical exam. This is just one example of how having the treatment plan you developed was rejected. Prior auths are challenging for nurse practitioners in many ways.
Lack of control.
Nurse practitioners may also feel frustrated and that they lack control of their patient’s care. I know I definitely have been frustrated by this. I went to nurse practitioner school to learn how to assess, diagnose, and treat patients. I completed the clinical hours and have built my clinical knowledge.
But so many times, I feel like my clinical decisions don’t matter. Instead I have to comply with what the health insurance company determines is medically necessary. I do understand why health insurance companies have these strict guidelines. They don’t want to have to pay for a test or medication when there are cheaper options.
But the lack of control in patient care is beyond frustrating.
I feel like going to nurse practitioner school was pointless. I shouldn’t even have to use my clinical judgment to figure out how to treat the patient, because first I have to check with the insurance company. This lack of control and challenges of the modern healthcare system contribute to nurse practitioner burnout. I have seen it time and time again. I personally feel the frustration and lack of control as a nurse practitioner.
Easing frustrations of prior authorizations
These are just a few of my frustrations when it comes to prior auths. Completing prior authorizations are not going away and will only get worse. As the cost of healthcare goes up, health insurance companies will tighten their regulations. There is no end in sight.
Because I can’t avoid prior authorizations, I have decided to change my outlook on the situation (it’s a work in progress). I have discovered a few tips for completing a seamless prior auth process and I will share them with you in this article: 11 tips to improve prior auth processes as nurse practitioners.
But in the meantime, please comment below and tell me if you struggle with prior authorizations just like I do!