The Controversial Prior Authorization Process: Care to Care has the Solution

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Prior authorizations have been a controversial topic in Health Care for the last decade. However, Care to Care has found a way to minimize misutilization and produce cost savings without being an obstacle to care.

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“We are proud to have been able to meet or exceed industry UM goals for all our clients; and have fostered a cooperative relation with all of the physician communities with which we work.” said Michael Komarow, MD, JD, EVP of Clinical Strategies at Care to Care.

Prior authorizations have been a controversial topic in Health Care for the last decade. A recent article by Joanne Finnegan published in fiercehealthcare.com stated that, “In a survey released this week by the Medical Group Management Association (MGMA), 83% of respondents said prior authorizations are ‘very’ or ‘extremely’ burdensome.”

“Having been involved in creating and managing the provision of Prior Authorizations (PA) for medical imaging for over twenty years, I found this statistic to be both predictable and sadly lamentable,” said Michael Komarow, MD, JD, Executive Vice President of Clinical Strategies at Care to Care, a Radiology Benefit Management company.

It is a fact that some systems seem to use delay as part of their Utilization Management (UM) strategy. Whether this is by design or neglect is of no consequence, it is not acceptable. More importantly, it is completely unnecessary. A well-designed PA program is limited to reviewing:

  • only procedures with significant misuse potential
  • only procedures with significant costs
  • using current evidence based criteria

There is nothing esoteric in creating such a program but administering it with patient welfare foremost is critical. At Care to Care, we have endeavored from day one to limit the burden we put on referring and rendering practices by asking as little of them as necessary to perform our UM tasks.

“We have built hardware and intellectual property with efficient processing in mind and have been willing to provide the clerical and physician participation to make sure that the inevitable gaps in automated procedures do not lead to delays”, continued Dr. Komarow. “We are proud to have been able to meet or exceed industry UM goals for all our clients; and have fostered a cooperative relation with all of the physician communities with which we work.”

About Care to Care:
Care to Care is a URAC and NCQA Accredited Specialty Benefit Management company that provides solutions to ensure payers and their beneficiaries receive cost-effective care by reducing inappropriate and unnecessary imaging as well as Utilization and Provider Network management to government, commercial, and self-funded programs. Learn more at http://www.caretocare.com.

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