Do care management departments manage prior authorizations (PAs) for medical services?

Care Management Departments and Prior Authorization Management

Care management departments do manage prior authorizations (PAs) for medical services as part of their essential role in coordinating healthcare delivery for patients with complex needs. 1, 2

Role of Care Management in Prior Authorization

• Care management teams serve as critical coordinators in the complex healthcare system, managing the confusing array of service providers, reimbursement mechanisms, and eligibility requirements that patients face 1
• When evaluating prior authorization requests for medical services, care managers first consult the member's certificate of coverage to determine if the requested service is a covered benefit 3
• After confirming coverage, the PA request is evaluated against organizational policies that establish criteria for medical necessity, using evidence-based guidelines 3

Team Structure and Responsibilities

• Prior authorization management is ideally handled by a multidisciplinary team including physicians, nurses, and/or social workers 1, 2
• The care management team must maintain a link to the patient's primary or continuing medical care to ensure appropriate medical guidance 2
• While one qualified health professional may perform care management functions, the process typically involves coordinating across multiple providers and care settings 2

Benefits of Care Management PA Handling

• Centralized management of prior authorizations by care management teams helps control unnecessary utilization and costs while ensuring quality of care 2
• This approach increases services and reduces unmet needs for patients with complex healthcare requirements 2
• Proper PA management can increase patient confidence in receipt of care and improve overall life satisfaction 2

Challenges in Prior Authorization Management

• The prior authorization process consumes significant time and resources, with provider respondents reporting time equivalent to more than 100,000 full-time registered nurses per year spent on prior authorization activities 4
• When the care manager is also a service provider, potential conflicts of interest may arise, affecting how guidelines are applied 3
• Services might be inappropriately provided based on agency profit rather than patient need, or conversely, inappropriately restricted if the manager is at risk for the cost of care 1, 2

Evolving Approaches to Prior Authorization

• Health organizations are increasingly looking to streamline prior authorization processes, with 65% of private payer respondents reporting plans to incorporate AI into the process in the next 3-5 years 4
• "Gold carding" and electronic/automated prior authorization processes are emerging as options for reducing administrative burden 5
• Patient-centered approaches to prior authorization are being developed to better direct health system resources to meet individual patient needs 6

Best Practices for Care Management PA Handling

• Care managers should apply evidence-based guidelines as specified by organizational policies to ensure consistent decision-making 3
• Patients and/or surrogates must be actively involved in the care planning process, including being promptly informed when services are denied or restricted 1, 2
• Care management teams should have knowledge of relevant clinical areas, expertise, and an understanding of cultural diversity to effectively manage prior authorizations 1