麻豆传媒

Are you and your staff sick of spending hours on the phone to get prior authorization for procedures and treatments your patients need? One New York City urologist thinks he may have an answer: doctors should bill the insurers for the time spent doing it.

"Prior authorization has become the single most important issue in healthcare," Alex Shteynshlyuger, MD, who is in solo practice in Midtown Manhattan, said in a phone interview. "It's a very critical service, because if patients don't get the prior authorization, they don't get the underlying service, and studies have shown outcomes are worse when a prior authorization is required but not [sought], or denied and not appealed."

Shteynshlyuger has applied to the Current Procedural Terminology (CPT) Editorial Panel to get approval for a CPT code for time spent on prior authorizations. The panel will consider Shteynshlyuger's application at its next meeting, which begins on Thursday.

Under the current system, "there's a problem of incentives and costs," he explained. "When a medical office does prior authorization, there's a disincentive to do that -- I take money out of my pocket to do it. I'm not compensated for that in any way." It goes against human nature to do anything to harm oneself, but that's exactly what happens with prior authorization, added Shteynshlyuger, who studied economics as an undergraduate.

Prior authorizations also make it more difficult to run an independent practice, which is why so few physicians do so, he noted. "A lot of private practices are not doing well," in part because of all the time they have to spend on prior authorizations and other administrative tasks.

On the other hand, Shteynshlyuger said, "health insurance companies have an incentive to [require] prior authorization, because the cost to them is minimal." He referred to a in which a doctor said she was fired from her job as a prior authorization reviewer at Cigna because she spent too much time reviewing requests. The article examined reviewer dashboards, which listed "a handle time of 4 minutes for a prior authorization. The bulk of drug requests were to be decided in 2 to 5 minutes. Hospital discharge decisions were supposed to take 4½ minutes."

But for a doctor's office like Shteynshlyuger's, "the time to get an insurer on the phone is 40 minutes," he said. "That creates a perverse incentive system. Health plans have an incentive to create as many PAs [prior authorizations] as possible, because each time [a service] is not done or denied, it goes straight to the bottom line of the health plan. They're not paying for service to the insured, and that is pure profit."

This is not the first time a payment for prior authorization time has been suggested, he said. For example, Harvard economist David Cutler, PhD, proposed a prior authorization payment scheme in his for the Hamilton Project on reducing administrative costs in healthcare [p.15].

"It's essentially the same idea, that you need to have plans pay for prior authorization, but Cutler proposed a different approach -- to build PA time into CPT codes," said Shteynshlyuger. However, with 70,000 health plans who each have their own prior authorization requirements, that could get difficult, he said. Another proposal involved using a prior authorization modifier for currently existing procedure codes, "but that complicates things."

But even if such a code -- which would be billed in 10-minute increments -- were to be approved, would insurers pay for it? Shteynshlyuger said they would.

"Responsible health plans would jump at the opportunity to reimburse, because according to health insurance plans, PAs are necessary," he said, quoting a of America's Health Insurance Plans, a trade group for health insurers, that says prior authorizations are "one of the many tools health insurance providers use to promote safe, timely, evidence-based, affordable, and efficient care. Under the supervision of medical professionals, prior authorization can reduce inappropriate care by catching unsafe or low-value care."

"So in no rational world would a health plan not want to pay for something that benefits the patient and is in the best interest of health insurance plans as well," he said. "This is a simple solution that realigns incentives properly ... It incentivizes health plans to require PA when it's truly needed, and incentivizes physicians [to make the effort] to do it properly to get medical care to the patient in the most efficient manner."

The proposed code would have to go through several steps before it could be put into use. If the proposal for a prior authorization CPT code is approved, it would then be reviewed by the Relative Value Update Committee (RUC) at its meeting in September. RUC recommendations would then be shared with the Centers for Medicare & Medicaid Services (CMS) for consideration by October. CMS would, in turn, review and announce its proposed coding changes and additions by July 2025. The earliest CMS would finalize and implement a CPT code approved at the May meeting would be Jan. 1, 2026.

Comment