True peer-to-peer conversations will improve prior authorization

It’s another busy day in my spine surgery clinic when my phone rings. Patients are waiting, but I’d be unwise to put off the caller: a physician calling from a health insurance company. This peer-to-peer call is part of the prior authorization process; my “peer” needs information to determine whether the company will cover a procedure I requested for one of my patients.

Sometimes the conversation goes uneventfully. The “peer” and I establish that the service is medically necessary, and it quickly gets approved. But it usually feels like talking to a wall — a distant voice reading scripted questions off a computer screen — and I sense this is a box-checking exercise destined to result in a predetermined denial. Missing is any discussion of the nuances of the patient’s case or the clinical reasoning behind my request, based on more than two decades of clinical practice and the thousands of similar patients I’ve treated.

That shouldn’t be a surprise, given that the caller is rarely a surgeon, let alone a spine surgeon like me.

With frustrating experiences like this, you might think I would join the chorus of providers seeking to do away with, or seriously rein in, prior authorization. But taking that position would be at odds with the realities of U.S. health care, not to mention what I witness regularly on the other side of the process. Because in any given week, I also work in utilization management — the field that includes prior authorization — and oversee peer reviewers like the ones who call my practice. The dual vantage points of receiving peer-to-peer calls as a practicing physician and working on the other end of the line give me an uncommon perspective on the issue, as well as confidence that there is a better way.

Honing a necessary tool

From my utilization management perch, I see first-hand why prior authorization is needed — requests for treatment doesn’t always line up with the evidence. Roughly 15% to 20% of requests I see for lumbar fusions, a common back surgery, don’t meet medical necessity criteria. In many fields, new innovations and evidence come at providers so fast they can’t keep up. It helps to have oversight and support from fellow experts whose job revolves around keeping up with the science.

But at an industry level, the system needs to work much better so it can address the administrative burden, delays, and frustration this often-antiquated process produces.

Efforts to modernize prior authorization should get a boost from a long-awaited rule by the Centers for Medicare and Medicaid Services, which was finalized in mid-January. Key provisions include requiring insurers to make decisions on urgent prior authorization requests within three days, and within seven days for other requests. The rule also requires health plans to report metrics for their prior authorization programs and to adopt new standards for data interoperability to support more efficient processing of electronic requests.

Used responsibly, artificial intelligence holds enormous promise to make prior authorization more efficient and effective. Imagine an AI-powered assistant that alerts providers to potential problems with their requests — like a missing imaging study — before they click to submit. Those issues could be quickly addressed, improving the odds of a speedy approval. A wave of improvements could emerge from this solution alone.

The human side of prior authorization

While technology and regulations hold a piece of the answer, the importance of high-quality human interactions can’t be overlooked. Peer-to-peer reviews are the most up-close-and-personal experience that providers have with the process, and they have the potential to make them either adversaries or advocates. A good peer-to-peer experience can feel validating and informative; a negative one can stick with a provider for years, leading to simmering frustration and disillusionment and potentially contributing to burnout.

The way forward is relatively simple: For certain specialties and whenever possible, providers should be able to discuss their prior authorization requests with true peers — spine surgeon to spine surgeon, oncologist to oncologist, physical therapist to physical therapist, and so on. Despite what “peer-to-peer” suggests, that practice is far from universal. I’m proud that the utilization management team I work with follows this approach — we’re all orthopedic spine surgeons or neurosurgeons who have treated patients like those whose cases we’re reviewing.

Few providers relish a peer second-guessing their clinical judgment, but it’s a far better experience when they know that the reviewer has been in their shoes. Instead of reading scripted questions, the pair can delve into the nuances of the case that are sometimes hard to express in a note. Provider and reviewer might share screens and look at the same imaging studies together. They can discuss the evidence base and the guidelines and figure out together what approach offers patients the best outcomes.

The results of those conversations can be surprising. Sure, there are times when reviewers steer providers away from inappropriate and overly aggressive treatments. Yet it can also go the other way. Consider a patient experiencing knee pain, who has tried all the appropriate conservative treatments — anti-inflammatory drugs, physical therapy, injections — and nothing works. She’s referred to a surgeon, who seeks the health plan’s authorization to clean up a worn-out part of the knee due to a tear in the meniscus and remove the arthritic buildup.

Thirty years ago, that procedure was standard practice. Evidence over time, however, has shown that it’s unlikely to lead to long-term pain relief.

This is where the value of a specialty-matched peer-to-peer conversation becomes apparent. Instead of simply denying the procedure, the reviewer could discuss new findings with the surgeon and suggest the patient might benefit more from a knee replacement than a knee scope. A knee replacement is more expensive, but it may be the better long-term solution for the patient.

Making prior authorization work better demands a recalibration of our approach — one that shifts from an adversarial to a more collaborative framework where the medical evidence, and what’s best for the patient, stays the focus.

Matthew Walker is an orthopedic spine surgeon and medical director of musculoskeletal surgery at Evolent, a specialty and primary care management company that works with payers and providers to achieve better outcomes for people with complex health conditions.