Prior authorization (PA) is still a hurdle for on–time care in endocrinology because treatments such as continuous glucose monitors (CGMs), insulin pumps, and hormone therapy still demand payer approval. Delays and denials can interrupt patient results, especially in ongoing diseases like diabetes and thyroid disease.
By making the following patient-centered practice changes, endocrinology practices can decrease PA processes, increase transparency, and provide faster access to life-altering therapy. These best practices are the easiest way to a prosperous, thriving clinic.
1. PA Burden in Endocrinology: Getting It
Challenge:
High volumes of PA-intensive work land in endocrinology clinics because of expensive, high-tech therapies. Payers ask for excessive paperwork, including documentation of unsuccessful first-line treatments or labs, resulting in administrative delays. Patients, on the other hand, feel frustrated and delayed in receiving treatment.
Patient–Centric Solutions:
- Rank High PA Services: Prioritize resources for therapy with the highest prior authorization requests (e.g., CGMs, growth hormone shots).
- Educate Patients Up-front: Set expectations and mitigate frustration by clearly explaining PA requirements during first encounters.
- Track PA Timelines: Utilize dashboards to keep track of approvals in progress and keep patients informed.
2. Automating PA Workflows
Challenge:
Slow and error-prone manual PA processes. Endless hours of searching for paperwork or fixing mismapped codes.
Patient-Centric Solutions:
- PA Software: Auto-populate PA forms with EHR data (e.g., A1C level, previous treatments) via software.
- Real-Time Alerts: Alert patients via patient portals or text messages when their PA is approved, submitted, or action-required.
- Integrate with Payers: Use EHR-integrated tools such as CoverMyMeds to submit PAs to payers electronically.
3. Improving Patient Communication
Challenge:
Patients are not considered meaningful to PA processes and are not aware that they play a part in providing supporting documents or appealing denials.
Patient-Centric Solutions:
- Dedicated PA Coordinators: Allocate employees to walk patients through prior authorization processes, such as appeals.
- Plain Language Alerts: Make use of plain-language vocabulary (e.g., “your insurer needs more information”) rather than jargon (e.g., “non-formulary”).
- Proactive Denial Management: Involvement of patients to fix denials using insurer comments and follow-up.
4. Profiting from EHR Integration for Effortless Documentation
Challenge:
Disparate systems in endocrinology practices need employees to switch between EHRs, labs, and insurer portals, introducing errors and delays.
Patient-Centric Solutions:
- Custom EHR Templates: Integrating PA checklists into EHRs to remind providers to document necessary metrics (e.g., BMI for anti-obesity medications).
- Auto-Attach Records: Automate EHRs to attach supporting documentation (e.g., thyroid biopsy report) to PA submissions.
- Centralized PA Dashboard: Provide patients with access to a portal showing PA status, action needed, and date of approval estimated.
5. Collaborating with Payers for Accelerated Speed of Approval
Challenge:
Payer requests are wildly different— e.g., UnitedHealthcare might approve CGMs with 14 days of glucose, while Aetna requires 30 days.
Patient-Centric Solutions:
- Payer-Specific Playbooks: Develop playbooks with individual prior authorization requests and doc format preferences by payers.
- Advocate for Patients: Educate staff to negotiate with payer representatives, highlighting medical necessity (e.g., risk of hypoglycemia).
- Enroll in Payer Programs: Register with insurer “gold card” programs that prevent low-risk providers from being eliminated from some PAs.
6. Rolling Out Patient Advocacy Programs
Challenge:
Target groups (e.g., elderly patients with diabetes) cannot possibly navigate PA processes themselves.
Patient-Centric Solutions:
- Community Partnerships: Partner with patient advocacy organizations or diabetes educators to help fill out PA forms.
- Financial Counseling: Provide advice on copay programs or alternate treatment if PA is denied.
- Multilingual Support: To minimize misunderstandings, provide PA documents in the patient’s language.
7. Monitoring PA Outcomes to Guide Improvement
Challenge:
Practices lack the tools to identify common causes of denial (e.g., missing modifiers) or payer delays without tracking prior authorization measures.
Patient-Centric Solutions:
- PA Analytics Tools: Monitor approval rates, denial reasons, and turnaround times by insurers using software.
- Patient Feedback Surveys: Get patients to rate their PA experience to discover pain points (e.g., not being informed).
- Staff Training: Fill gaps with role-playing exercises emphasizing empathy and efficiency.
Patient-focused prior authorization practices can allow endocrinology practices to minimize delays, lower administrative burdens, and develop trust. Strategies include automating, streamlining communications, and closely collaborating with payers and patients. A great way to improve service is to outsource the back-end work to a dedicated PA service. Integrating PA processes with the patient’s needs will allow practices to obtain quicker access to necessary therapies and establish long-term loyalty and satisfaction.
