evp, public policy & advocacy senior manager, practice ... · the average of 37 weekly prior...

Kathleen Zwarick, PhD, CAE—EVP, Public Policy & Advocacy

Joel Dunay, MS—Senior Manager, Practice Management

Susan L. Crews, CPC, ACS-UR, PCS—Manager, Reimbursement Policy

Montgomery County Medical Society

Kathleen Zwarick, PHD, CAE, is the Executive Vice President of Public Policy & Advocacy for the American Urological Association. She has been a C-suite executive for more than 25 years and has testified before federal agencies, presented at state and national associations on advocacy strategies and improving stakeholder engagement; successfully created new and revised nursing home CPT codes, and was awarded the Centers for Medicare & Medicaid Services Administrator’s Special Citation Award for her role in increasing implementing a campaign to improve dementia care.


Susan L. Crews, CPC, ACS-UR, PCS, is a healthcare management professional that has specialized in urology coding, billing and training for over 17 years. As Reimbursement Policy Manager for the American Urological Association, Mrs. Crews plays a lead role in analyzing American Medical Association‘s (AMA) Relative Value Update Committee (RUC), Current Procedural Terminology (CPT), and International Classification of Diseases (ICD) diagnosis data and contributes to the strategic direction of all reimbursement activities. She leads research and analysis of all public and private payor policies, particularly coverage and reimbursement policies, as well as coding issues.


Joel Dunay, MS, is Senior Manager of the Practice Management Department for the American Urological Association. Presently, I have worked three years at the American Urological Association in the Practice Management Department where I held the position of Outreach Specialist, then moved to Senior Manger in 2015. Previously, I spent 17 years at MedStar Union Memorial Hospital in Baltimore, Maryland as Practice Manager for Cardiac Rehabilitation, Endocrinology and Infectious Disease. I graduated from West University with a double Master’s Degree in Sports Medicine and Exercise Physiology.


Objectives

• About the AUA

• Prior Authorization

– What is Prior Authorization?

– Impacts on Provider Practices

– What is the AUA doing?

• Challenges for Practices in 2017

– Reimbursement Reduced Compensation

– Responding to Payment Methodologies

– Administrative Burdens

– Workforce Issues

• Questions?


About the AUA

• 21,000 urologists

• 8 Regional Sections, 34 state societies

– Maryland Urologists for Patient Access and Care

– 267 Maryland-based urologists

• Public Policy and Practice Support Division

• Reimbursement & Regulation

• Practice Management

• Government Affairs & Advocacy

– State and County Advocacy: John Kristan

• Patient & Research Advocacy


Prior Authorization: Is it a Burden?

Susan Crews, CPC, ACS-UR, PCS

Reimbursement Policy Manager


What is Prior Authorization?

• Prior Authorization is approval that a physician must receive from the patient’s insurance company before performing a particular procedure or prescribing a specific medication

• Without prior authorization, the insurance company may not provide coverage and/or reimbursement


Why does my patient’s health insurance require authorization?

• Insurance companies use prior authorization as a way of keeping health care costs down

• Services are not being duplicated

• Is the procedure or medication truly a medical necessity


What consequences can a PA have on my practice?

• Increase the burden on physician’s and staff to complete necessary requirements

• Hinders patient’s timely access to treatment

– Medication

– Devices

• PA may result in a delay of treatment causing a patient’s illness to progress


Prior Authorization Affects All Physicians

• The American Medical Association has been working on this issue for years!

• https://www.ama-assn.org/practice-management/addressing-prior-authorization-issues


https://www.ama-assn.org/practice-management/addressing-prior-authorization-issues

AMA Survey Overview

• 1,000 practicing physician respondents

• 40% PCPs/60% specialists

• Web-based survey

• 24 questions

• Fielded in December 2016

2017 American Medical Association. All rights reserved.


Weekly Average Number of PAs & Processing HoursThe average of 37 weekly prior authorizations per physician takes the equivalent of

approximately two business days of physician/staff time to process (16 hours).

Combined Number of Prior Authorizations in Past Week

Combined Number of Hours Spent Processing PAs in Past Week

Mean: 36.6 Median: 20.0 Range: 0-750 Mean: 16.4 Median: 8.0 Range: 0-200

23%

23%

23%

17%

14%

0%

20%

40%

60%

80%

100%

Prescription + Medical Services

0-5 PAs

6-10 PAs

11-20 PAs

21-40 PAs

Over 40 PAs

22%

19%

23%

23%

13%

0%

20%

40%

60%

80%

100%

Physician + Staff Combined

0-2 hrs

3-5 hrs

6-10 hrs

11-20 hrs

Over 20 hrs



Survey Takeaways: Practice Burdens

• 75% of surveyed physicians described prior authorization burdens as high or extremely high

• More than 1/3 of surveyed physicians reported having staff who work exclusively on prior authorization



Survey Takeaways: Patient Impact

• Nearly 60% of surveyed physicians reported that their practices wait, on average, at least 1 business day for prior authorization decisions—and over 25% of physicians said they wait 3 business days or longer

• 90% of surveyed physicians reported that prior authorization sometimes, often, or always delays access to care



The Alliance of Specialty Medicine Access to Specialty Care Workgroup

• Recently launched a survey to study the impact on PA on practices

– 1,000 responses to survey

• 94% of respondents noted that increased administrative burdens by insurers have influenced their ability to practice medicine.

• 93% of respondents have prescribed something else due to delay tactic by insurers related to the original/first-choice prescription.


What is the AUA doing?

• AUA Prior Authorization Toolkithttp://www.auanet.org/advocacy/advocacy-by-topic/prior-authorization


http://www.auanet.org/advocacy/advocacy-by-topic/prior-authorization

AUA Conducted Survey of PMN Members

• A Snap Survey sent to Practice Managers’ Network assessing employee burdens and characterizing various payers.


AUA Conducted Survey of Practice Managers

• Most practices indicated a designated staff person to conduct the prior authorization process, usually and administrative employee, billing staff person, or medical assistant.

• The time staff spends on authorizations ranges from 15-30 minutes per claim and 2-4 hours of total time per day.

• Across the board, the most effective way to streamline the prior authorization process was to create a universal form and requirements to which every insurance provider must adhere.


Tips for Handling Prior Authorizations

• Make sure that you have met all of the insurer’s criteria before submitting a request

• Make sure you are following recommended treatment guidelines before ordering unnecessary procedures

• Use the insurer’s website to look up information rather than contacting them via telephone

• Designate one or two individuals to handle all prior authorizations for the entire practice. These individuals must have access to all of the patients’ records and physician notes


Top Issues In Medical Practices

Joel Dunay, MSSenior Manager Practice Management

American Urological Association


The Landscape of Medical Practice

• Economy: Revenues are down

• Regulations: more complex and harder to manage

• Costs: higher than ever

• Fewer Opportunities: decrease in ability to provide ancillary services

• Payment rates: In network plans keep cutting payments and out of network payments linked to Medicare rates

• Coding and compliance challenges

• Fewer residents enrolled in medical school to take over aging provider population.


Top Four Challenges for Practices in 2017

1. Reimbursement And Reduced Compensation

2. Responding to New Payment Methods

3. Administrative Burdens

4. Workforce Issues


Lower Reimbursement and Different Payment Methods

• Previously, lower reimbursement was the chief concern for providers

• Presently, risk-based payment models (coupled with continued decreases in reimbursement) have also emerged to share the stage with fee-for-service payments, thus creating another layer of complexity for providers

• Prospectively, providers will be charged and held accountable by payers and even patients to continue “doing more with less”


Changing Payment Models

•Providers paid a specified amount for each service providedFee-for-Service

• Incentives for higher quality measured by evidence-based standardsPay-for-

Performance

•Percentage reimbursement at risk, earned back by high quality outcomes.

Value-based Purchasing

•Single payment for episodes of treatment, shared by hospital and physicians.

Bundled Payments

•Percentage of savings from reduced cost of care shared with hospitals and physicians.Shared Savings

•All services compensated in one payment that manages the patient across the delivery systemGlobal Payments

Incr

eas

ing

Pro

vid

er

Ris

k


Quality Payment Program

• Quality Payment Program also known as MACRA

– Advanced Alternative Payment Models (APMs)

– Merit-based Incentive Payment System (MIPS)

Quality

Advancing Care Information

Improvement Activities

Cost


Workforce Shortage

• New study released by the Association of American Medical Colleges (AAMC). The latest projections continue to align with previous estimates, showing a projected shortage of between 40,800 and 104,900 doctors.

• By 2030, the study estimates a shortfall of between 7,300 and 43,100 primary care physicians. Non-primary care specialties are expected to experience a shortfall of between 33,500 and 61,800 physicians.


Workforce Shortage

• New AUA Policy Statement on Physician Workforce and Graduate Medical Education Advocacy:

“The American Urological Association continues to endorse the 2015Association of American Medical Colleges Statement on the Physician Workforce. The American Urological Association believes that the projected number of urologists-to-population ratio of the United States is inadequate to keep up with projected population growth. Existing shortages are exacerbated by inadequate numbers of residency positions and lengthening time of training. In order to meet urology’s workforce shortage, it has become necessary to meet the triple challenge of providing more urology training positions with more extensive training in a shorter duration of time. Work must be done to move the national discussion away from focusing solely on primary care needs and advocate a new focus on the entire physician workforce.”


Administrative Burdens

• Electronic Health Records (EHR)

• High cost to maintain and support with multiple upgrades

• The Office of the National Coordinator of Health IT (ONC) estimates cost of an in-office system at $33,000 and software costs up to $4,000 annually.


Administrative Burdens

• Prior authorizations – main source of administrative drain for medical practices.

• On average 20 hours per week physicians spend on prior authorizations.*

• Average cost of $83,000 to medical practice (equal to 1.5 EFT).

* Based on 2015 Health Affairs Study


Moving Forward Strategies

• As the industry continues to shift to a value-based paradigm (and respond to programs such as MACRA and MIPS), practices will keenly feel the effect and will likely be prompted to consider strategic action.

• Likewise, as the workforce continues to age, practices will need to consider partnership’s to continue providing assistance with recruitment and staffing


Moving Forward Strategies

• Developing alignment models that seek to improve on the historical methods of alignment and create a more clinically integrated relationship that capitalizes on the value-based reimbursement paradigm.

• Implementing best practice solutions for optimizing effective practice operations.


Questions


Contact Information

Kathleen Zwarick, PhD, CAE

[email protected]

(410) 689-3703

Susan Crews, CPC, ACS-UR, PCS

[email protected]

(410) 689-4045

Joel Dunay, MS

[email protected]

(410) 689-3710


mailto:[email protected]



evp, public policy & advocacy senior manager, practice ... · the average of 37 weekly prior...

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