DME Prior authorization is frequently employed in the case of overpriced prescription medications. DME Prior authorization is used by health insurance companies to ensure that a specific drug, surgery, or therapy is medically essential before it is performed or prescribed. Simply said, it is the process of obtaining clearance from your health insurance provider (rather than your doctor) to acquire a prescription or treatment.
Although it is a time-consuming procedure, the ultimate goal of Prior authorization is to improve patient outcomes by guaranteeing that they obtain the correct medication while eliminating waste, mistake, and inappropriate prescription drug use and cost. It is all about keeping healthcare costs in check. With more discretion over which drugs health insurance companies would pay for, they may supply more expensive medications to individuals who need them.
Can medications be denied due to improper following?
Prior authorization is required for around 66% of prescriptions. When a DME Prior Authorization requirement is approved, just 29% of patients follow proper instructions/guidance regarding the medication/therapy, whereas around 40% discontinue therapy completely. Not only is this bad for pharmaceutical companies, but it also frustrates patients who don’t follow the medication that would best treat their ailment, or who don’t take any therapy at all.
Is DME Prior Authorization worth the time and cost?
There are several reasons why DME Prior Authorization is required. Although prior permission is intended to reduce costs, it necessitates a significant amount of administrative effort, phone calls, and repetitive paperwork by both pharmacists and doctors. We will go into the issues that the process poses and why it is so difficult to manage in the following sections.
Doctor’s Effort and cost
According to Medical Economics, many physicians have long expressed frustration with the amount of time they and their employees had to spend working with health insurance. When a prescription needs to be authorized, it requires a significant amount of administrative work. Including the time a physician must spend convincing an insurance company to fund an expensive drug or service; physicians must complete several processes to obtain most DME Prior Authorizations.
This can include obtaining the relevant form, filling out the form with the necessary information, submitting the form to the plan, and so on. Unfortunately, they are not alone; according to a survey, 84% of responding physicians felt the load of DME Prior Authorization is moderate to severe. Another 86% of physicians stated that the load of DME Prior Authorization has increased over the last five years, reducing the time that physicians needs to spend caring for their patients.
The actual cost
Although DME Prior Authorization has been a concern for healthcare practitioners for many years, little is known regarding the cost to individual practices or the healthcare system as a whole. According to one study published in 2009, DME Prior Authorization requests occupied almost 20 hours per week per medical practice, one hour of the doctor’s time, roughly six hours of secretarial time, and 13 hours of nurses’ time.
According to an Insurance Affairs research, when the time was converted to cash, practices spent an average of $68,274 per physician each year communicating with health plans. This amounts to between $23 billion and $31 billion per year; hence DME Prior Authorization ultimately costs huge money.
What changes may be made to enhance the DME Prior Authorization process?
Although DME Prior Authorization is an unavoidable step in many practices, the existing procedure is all too often manual, involving:
In a time-consuming flow of information that can lead to treatment delays and frustration for everyone. As a result, many organizations are introducing electronic prior permission solutions to address common approvals challenges.
Electronic DME Prior Authorization connects directly with electronic health records (EHRs). It allows healthcare practitioners to readily get DME prior authorizations at the point of treatment in real-time. This also saves time by eliminating the need for paper forms, faxes, and phone calls.
Understand the insurer’s policy
To avoid patient delays, physicians must check DME Prior Authorization requirements before performing treatments or submitting prescriptions to pharmacies. Even brand-name medications are the two most prevalent procedures for which insurance needs DME prior authorization. As a result, doctors should be aware of insurer regulations and create a list of drugs that are covered by all insurers for common disorders.
Use a unified database
By unifying the obligation for DME Prior Authorization, practices can typically offer greater efficiencies. Many practices and health systems now lack clearly defined duties when dealing with DME prior authorization or simply lack sufficient time.
By putting one or two people or a department in charge of DME prior authorizations for the entire system, those employees will be able to become extremely competent in the process to create connections with payers. A centralized system also addresses inconsistency and guarantees a more dependable and stable approach.
Even though the DME Prior Authorization process is an integral and the most vital part of any healthcare firm. It still goes through a lot of hurdles even in this current scenario. As mentioned above the process can be quite complex if it’s not dealt with someone who has expertise in these matters. Overall, DME Prior Authorization does bring profit to the organization if it follows the above protocols which do not only make the process more integrated but also make it simpler for your clients.