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Private Payer Issues
If you contract with private payers, you've dealt with your share of administrative challenges related to these payers’ efforts to control costs, including the use of prior authorizations, as well as their medical claims billing practices. Learn how to navigate issues physicians commonly encounter when working with private health plans.
Prior Authorizations: What They Are and How to Make Them Easier
What are prior authorizations?
Prior authorizations are a top private payer issue among physicians overall and one of the biggest sources of administrative burden for family physicians. Prior authorizations are a mechanism health insurers use to control costs by which physicians must obtain approval from the patient's health plan before providing a specific service or medication to the patient.
How can the prior authorization request process be improved?
The best way to address prior authorizations would be to greatly reduce and, in many cases, eliminate them. The vast majority of prior authorizations are not clinically relevant.
The AAFP policy on prior authorizations outlines the challenges prior authorization requests present for family physicians and solutions for simplifying them.
Until unnecessary prior authorizations are eliminated, standardizing your processes can alleviate some of the burden associated with submitting them.
What can I do to make prior authorizations easier?
To speed up prior authorizations, you can use these tips:
- Use one or more dedicated staff to submit prior authorizations
- Submit prior authorizations electronically
- Customize your EHR, if possible, to remind yourself what information should be included in a prior authorization request
- Develop a prior authorization cheat sheet for the most common medications and procedures that require prior authorizations
Details about these tips and more can be found in a brief Family Medicine Practice Hack video recorded by one of your family physician colleagues. Considering the burden of prior authorizations, it may be the best five minutes you’ve spent in a long time!
You can also check out the Prior Authorization Cheat Sheet Workbook below, where you’ll find templates you can customize for all your payers. Standardize your prior authorization workflow by including the information each payer needs to approve a given service or medication. By prepopulating clinical documentation and diagnosis requirements for each service, along with the appropriate codes to use, you can save time and minimize burden.
Identifying Payers That Accept Supplemental Data
It is the policy of the AAFP that health plans should provide a mechanism for physicians in value-based contracts to submit supplemental data for all lines of business. The Academy tracks what payers accept supplemental data for the top five payers with whom the AAFP has relationships.
The AAFP developed model guidance which states, “In addition to receiving HEDIS data via claims and encounters, [payer] should also accept submission of supplemental data to satisfy HEDIS measures and close gaps in care in value-based contracts.” The consequences of a health plan’s inability to accept and record data may result in physicians not receiving payment otherwise earned under a value-based contract.
Payers That Accept Supplemental Data
| HEALTH PLAN | COMMERCIAL | MEDICARE ADVANTAGE | COMMENTS |
| United Healthcare |
Yes | Yes | |
| Humana | Yes | Yes | |
| Cigna |
No | No | Cigna Collaborative partners can use the iCollaborative software to manually attest to gap closure, thus improving their quality scores and gap closure rates. |
| Aetna | No | Yes | Aetna is considering accepting supplemental data for their commercial business as their systems evolve. |
| Anthem | No | Yes | Anthem is working to have a process in place to accept supplemental data for commercial business in 2019. |
AAFP Advocacy and Private Payer Issues
The AAFP private payer advocacy agenda includes but is not limited to:
- Holding private payers accountable for a commitment to increase investment in primary care.
- The need for payers to support practices in value-based payment contracts.
- Advocating for reduced or eliminated prior authorizations.
- The need for administrative simplification by advocating for the adoption of the Core Quality Measures Collaborative’s measure sets.
The AAFP advocates to the four largest health insurance plans for family physicians.
Are You Having a Problem With a Payer?
Follow these steps:
- Contact the payer directly.
- Reach out to your local chapter for help.
- If the problem persists, contact the AAFP at (800) 274-2237.