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 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.
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.
To speed up prior authorizations, you can use these tips:
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.
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.
|HEALTH PLAN||COMMERCIAL||MEDICARE ADVANTAGE||COMMENTS|
||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.|
The AAFP private payer advocacy agenda includes but is not limited to:
The AAFP advocates to the four largest health insurance plans for family physicians.
Follow these steps: