Image by Nattanan Kanchanaprat from PixabayPrior authorization has long been one of the most frustrating challenges in outpatient surgery.
For ambulatory surgery centers (ASCs), where speed and access are supposed to be big advantages, prior authorization often feels like the opposite, sources told ASC News. And even with the U.S. Centers for Medicare & Medicaid Services (CMS) and major payers promising change, ASC leaders and technology vendors say the problem is still very much there.
“Prior authorizations have been the bane of health care for quite some time,” Brandon Theophilus, vice president of solutions at NextGen Healthcare, told ASC News. “The process, the frustrations, the delays, the rejections, the related appeals, all of which obviously cause frustration to patients.”
The burden is especially acute in ambulatory surgery centers, where the promise of lower costs and faster access is often undermined by payer roadblocks, Theophilus said.
“Having the block or the barrier of prior authorizations has been an impediment to patient access,” he said.
Still, the logic behind prior authorization is rooted in medical necessity, James Becker, CEO of TriasMD, told ASC News.
“Prior authorization is in place from a payer perspective to make sure that … work to be done, whether you call it a surgery or procedure, is medically necessary,” Becker said. “That’s why they put it in place.”
But Becker acknowledged the frustration operators feel when the process drags on.
“Prior authorizations are something that are always going to exist,” he said. “They’re not going to go away. I think the opportunity on prior auth is for payers to make sure there’s only prior authorization in place for those things that are truly necessary.”
He described TriasMD’s approach to obtaining prior auths as an ongoing process. TriasMD is the company behind DISC Surgery Centers, which operates spine, orthopedic and pain management facilities across California.
“Prior authorization is a process for us,” Becker said. “It’s not just an event that occurs. We manage it very carefully and quickly to make sure we’re incredibly efficient.”
In the best cases, Becker said approvals can come in under two days.
“Most of the time it works well, 24 to 48 hours can be achieved,” he said. “However, there’s several examples of when it does not work well. Somebody will drop the ball. But on our end, this is such an important process to give the right access for our patients and to make sure they get scheduled as quickly as possible.”
The CMS payer pledge
In June, CMS and major insurers announced a voluntary pledge to reduce prior authorization burdens.
The pledge included commitments to reduce the number of services requiring prior authorization, standardize electronic processes by 2027, ensure continuity of care when patients switch plans, improve communication on determinations, expand real-time responses, and require medical review for denials.
Coordinated by AHIP and the Blue Cross Blue Shield Association, the initiative covers Medicare Advantage, commercial insurance and managed Medicaid. It included insurers like Aetna, UnitedHealthcare, Humana and Cigna.
Theophilus called it a symbolic step.
“There’s nothing binding, best I can tell with any of that. I think of it as a handshake,” he said. “But at the same time, when we have the health insurers coming together and saying out loud their commitment to ease the burden and the barrier of prior authorizations, that is a good thing.”
For technology vendors, the pledge opens the door for more automation, he said.
“This is not necessarily a problem of any of our creation,” Theophilus said. “What we hope to be able to do, and certainly this handshake agreement from June only gives more promise, is to allow technology to play an even greater hand in navigating the prior authorization process.”
Operators should temper expectations regarding the pledge, Becker said.
“I don’t think anybody would have expected to see that yet, because remember the first thing is to choose what to impact,” he said. “They have to decide where they need prior authorization and where they don’t. And then they have to figure out how to reduce the friction points.That takes time. I would not have expected we’d see this take the systems quickly. I think it would be naive to think otherwise.”
Technology and AI
Technology is already reshaping how prior authorization is handled, Theophilus said.
“AI is absolutely playing a role in automating the prior authorization process. I’ve taken a look and met with several of these various entities that are putting out AI agents for this. Some of them are better than others, but there’s absolutely a role,” he said.
NextGen is an IT solutions and EHR systems provider for ambulatory surgery centers and other health care organizations.
“There’s still going to be a human element involved, and that’s another service that NextGen offers, where we do have an augmented staffing capability to help practices where we can provide staff who will help work those exceptions,” Theophilus said.
AI is advancing rapidly, Theophilus said.
“AI has been around for some time,” he said. “The speed with which innovation is happening today, specifically around AI and in healthcare, is remarkable. Some days, just being candid, it can be even a little terrifying.”
“I suspect within a year’s time, we will be so much further along in terms of automation, intelligent automation, than where we even are today.”
Commercial payers and inconsistency
While CMS and Medicare has grabbed headlines, Stacy LaLonde, vice president of payer strategy at Compass Surgical Partners, said commercial carriers remain the bigger obstacle for ASCs.
“Medicare prior authorizations haven’t been a big barrier for us in our industry,” she told ASC News. “On the commercial side, it’s still a major barrier.”
North Carolina-based Compass Surgical Partners is a management and development company that partners with physicians and health systems to build and operate ambulatory surgery centers across the United States.
Inconsistent requirements are a big part of the issue, LaLonde said.
“There’s not a consistent approach to what procedures need prior auth and what procedures don’t across our commercial book of business, across the commercial carriers, there is inconsistency,” LaLonde said.
That unpredictability creates workflow headaches.
“They don’t know until they go to schedule a case whether a case requires an authorization or not, and it’s inconsistent. If we knew every single case that required an authorization, I think we’d be a little bit more efficient with our process,” LaLonde said.
For example, she said Inspire, an implant procedure for sleep apnea, is a case that is often difficult to obtain prior auth for.
“You have to prove that the patient has gone through a sleep test, has done everything they can to address their issues from a sleep quality standpoint, in order to get approved for this,” LaLonde said.
Looking forward
While payer cooperation would be nice, rigorous internal processes can also help, Becker said.
“Managing this process well really matters,” Becker said. “We’re very dialed in and focused on daily execution to get prior authorizations. But it takes both parties coming to the table to make this happen efficiently and effectively.”
And health systems may need to lead the charge, LaLonde said.
“As an independent negotiator, I have less power to change those things,” she said. “Sometimes health systems are able to have a lot more success. If you have a lot more bargaining power at the table, you’re able to force the payers to add certain language to contracts.”
And the role of technology should not be understated, Theophilus said.
“The role that technology can play in helping speed and navigate through that process is real, and that only gives us more hope,” he said.
