Can Primary Care Providers Call Insurance Companies Directly for Prior Authorizations?
Yes, as a primary care provider, you can and should call insurance companies directly to obtain prior authorizations for your patients. This is a standard practice responsibility, though it comes with significant administrative burden.
Understanding Your Role in Prior Authorization
- Prior authorization requires prescribers to obtain preapproval from the health plan before a medication or service will be covered, often requiring clinical information about the medical necessity of the treatment 1.
- Primary care practices spend substantial time on prior authorization requests—approximately 20 minutes per prior authorization event on average, with this time representing significant administrative burden on clinical teams 2.
- Provider employees collectively spend time equivalent to more than 100,000 full-time registered nurses per year on prior authorization across the healthcare system 3.
Practical Approach to Handling Prior Authorizations
Direct Communication Strategy
- You or your designated staff can directly contact insurance companies to initiate and complete prior authorization requests 1.
- Working with local pharmacy resources and pharmacy professionals can help jointly address prior authorization requirements, particularly for medication-related requests 4.
- Electronic Health Record (EHR) system use can reduce prior authorization time by approximately 5 minutes per request, making the process more efficient 2.
Documentation Requirements for Success
When calling insurance companies, ensure you have the following information ready:
- Specific details about the patient's condition, diagnosis, and relevant clinical measurements with source documentation 4.
- Clear identification of the treatment requested with indications supported by evidence and/or guideline statements 4.
- Documentation of previous therapies used and rationale for switching to or adding the requested treatment 4.
- Known contraindications, potential adverse effects, and steps intended to minimize risks 4.
- Evidence that delays or interruptions in therapy may cause harm to the patient when applicable 4.
Reconsideration and Appeals Process
- If a prior authorization is denied, reconsideration appeals serve as an initial review before a formal appeal process begins, allowing you to submit additional clinical documentation that may have been missing 4.
- Don't hesitate to appeal decisions that are contrary to best patient care, as this is part of your advocacy role for patients 4.
- Document all steps taken in the prior authorization and reconsideration process in the patient's health record 4.
Common Pitfalls to Avoid
- Not specifying the medical necessity of the requested treatment can lead to continued denials 4.
- Failing to engage pharmacists who may have expertise in navigating insurance coverage and patient assistance programs represents a missed opportunity for support 4.
- Medicaid requests typically take less time than private payer requests (approximately 6 minutes less), so adjust your time expectations accordingly 2.
Administrative Burden Considerations
- Prior authorization requirements from health insurance companies place substantial administrative and financial burdens on primary care offices, with physicians concerned about additional workload and workplace inefficiency 2.
- Coverage for treatments may require prior authorization or certification that the patient is receiving counseling, but the clinical benefit to patients makes this effort worthwhile 1.
- Health plans and employers pay pharmacy benefit managers (PBMs) fees for utilization management, including prior authorization requests, making this a standard part of the healthcare system 1.