Prior Authorizations (PAs) have a significant impact in ophthalmology because of the specialty’s mix of chronic disease management and procedure-heavy care. For example, conditions such as retinal disease (eg, age-related macular degeneration, diabetic macular edema) often require time-sensitive treatment, and delays in approval for injections may directly affect vision outcomes. Similarly, for patients with non-healing corneal epithelial defects, delays in PAs for medications may directly impact the cornea and lead to further decompensation during the waiting period, also complicating patient care.

“In clinical practice, I have encountered patients with painful dry eye disease who would have benefited from newly approved pharmaceutical therapies. However, the prior authorization process created significant delays in initiating appropriate treatment,” says Cynthia Matossian, MD, FACS, president and founder, American College of Eye Technicians (ACET), and founder and former medical director of Matossian Eye Associates in Pennsylvania and New Jersey. “In several cases, the initial request was denied, requiring additional documentation and a lengthy appeals process before approval was ultimately granted. This experience highlights a system that is neither patient‑centric nor supportive of efficient, evidence‑based clinical decision‑making for physicians.”

PAs also create a significant burden on staff. For example, staff can spend hours on payer portals, faxing forms, and following up—especially for high-frequency services like anti-VEGF injections, dry eye, and glaucoma medications. Another challenge practices must contend with is inconsistent payer rules, where requirements vary widely across insurers, even for the same drug or procedure. Also, step therapy and documentation expectations can also change without notice, further delaying care.

“In my practice, I have observed the significant burden that prior authorizations place on clinical staff,” says Dr. Matossian. “The process not only consumes the time and expertise of senior technicians, but it also contributes to a sense of frustration and demoralization. Over time, the repetitive administrative hurdles can 'wear down' even the most dedicated team members, ultimately contributing to technician burnout.”

Felecia Jones, COT, BBA, Eye Specialty Group, in Memphis, Tennessee, also notes the strain that PAs can place on staff. “In my practice, there have been instances where we secured an approved prior authorization for a medication, only for the pharmacy to persuade the patient that the generic option is both less expensive and equally effective. As a result, we are contending with challenges from both the insurance company and the pharmacy.” 

So, what can practice owners do to make the PA process simpler and more efficient? Ophthalmology Management spoke with Ms. Jones, Dr. Matossian, and Robert F. Melendez, MD, founder and CEO of Juliette Eye Institute in Albuquerque, New Mexico, who shared what has worked in their practices.

Create Standardized Workflows

Designate Dedicated PA Staff

Specialization improves speed and accuracy, says Dr. Matossian. “Instead of spreading responsibility across clinical staff, have a dedicated team responsible for PAs or ‘authorization pods’, cross-trained billing and clinical liaisons, and clear escalation pathways for denials/peer-to-peer reviews,” she explains.

Dr. Matossian also stresses the importance of ongoing training. “Since payer rules change often, ongoing training prevents avoidable denials,” she notes. “Another helpful tool for staff is tracking payer-specific requirements by creating and maintaining a living ‘payer playbook’ so staff know exactly what each insurer wants.”

When it comes to standardizing workflows, staff shouldn’t reinvent the process each time, Dr. Matossian says. “Instead, create diagnosis-specific PA checklists that simplify the process for staff. For example, this can include checklists for retina injections, glaucoma drops, dry eye medications, cataract-related testing, etc.”

Like Dr. Matossian, Dr. Melendez advises having a dedicated team for PAs rather than distributing the responsibility across multiple roles. He also recommends establishing clear performance metrics, such as turnaround time and approval rates. “This ensures that clinical staff are not pulled into administrative tasks that do not generate revenue,” he explains.

Dr. Melendez also recommends using automated communication tools, such as text or email updates, to help reduce the time staff spend making inbound calls and providing repetitive explanations to patients.

Another way to simplify the process for staff is to create a closed-loop workflow, he says. “Practices can do this by defining a clear pathway: start with the prescription, then prior authorization submission, then approval, then pharmacy fulfillment, then patient confirmation. Assigning ownership at each stage ensures that cases do not stall and staff are not duplicating effort.”

Ms. Jones adds that when it comes to PAs, “staff need to be trained and skilled in reading chart notes, understanding medications, and using electronic platforms for prior authorizations.” She also stresses that “documentation is critical and must include the need for medication, previous therapies tried, and why the recommended medication would be more beneficial than other therapies.”

Add Technology to Streamline Work

Dr. Matossian suggests using electronic medical record (EMR)-integrated electronic prior authorization (ePA) systems for real-time submission and status tracking; automation tools to auto-fill forms and pull clinical data; and dashboards for tracking pending/expiring authorizations. In addition, she says practices can also use artificial intelligence (AI)–assisted documentation that maps clinical notes to payer criteria. “Leveraging ePA tools also reduces phone and fax cycles and speeds approvals,” she explains.

Dr. Melendez recommends using platforms such as CoverMyMeds and Availity to reduce phone-based work, streamline submissions, and provide visibility into status. In terms of AI documentation support, he recommends tools such as Cora Scribe (Nextech) to ensure documentation is complete at the time of the visit, which further helps to reduce denials and delays. Also, Dr. Melendez explains that building structured templates instead of relying on free text and integrating PA triggers into prescribing workflows can further assist with EMR system optimization. 

Ms. Jones also recommends CoverMyMeds and Surescripts, explaining that health care organizations need to enroll in platforms that make it easier to complete required information.

Be Upfront With Patients

Patients rarely understand why care is delayed and often blame the physician and/or the staff, Dr. Matossian explains. To address this, she points out that “proactive communication such as scripts and handouts can reduce frustration and improve trust; however, most patients still expect expedited care and treatment.”

Further, to help meet patient expectations, especially for chronic therapies, she recommends initiating reauthorization before expiration to avoid treatment gaps. Also, she says, especially in retina care, having clear protocols for therapeutic interchange (when allowed) can prevent delays.

Dr. Melendez recommends avoiding repeated communication with patients. Instead, he recommends telling patients when the prescription is written that insurance approval may take several days. Standardizing the process before the prescription is sent is also important, he explains.

Dr. Melendez also points out that many inefficiencies occur after the prescription is written, but that is too late in the process. “To address this, identify medications that commonly require prior authorization before they are prescribed, use standardized documentation templates aligned with payer requirements, and ensure all required clinical data is captured during the visit.” 

Thoughts on Policy

When it comes to policy, Dr. Matossian says that gold-carding programs (waiving PAs for high-approval providers), standardized payer criteria across insurers, limits on turnaround time (for example, 24 to 48 hours for urgent ophthalmic care), and reduced repeat PAs for chronic, stable conditions would have the highest long-term impact.

“A grander, idealistic solution is for the entire ecosystem of governmental agencies, insurance carriers, industry, medical device, and pharmaceutical companies to legally work together to eliminate the suffocating burden of PAs by remembering that patients’ medical needs are the #1 priority,” she explains.

Regarding policy, Ms. Jones adds, “Premiums are too expensive for medications not to be covered. There should be a government law requiring that new medications be tried once, regardless of cost, to determine their effectiveness, especially if there is documentation that previous therapies have failed or that, based on the diagnosis, the preferred medication would be beneficial.” OM

Dr. Matossian, Dr. Melendez, and Ms. Jones report no relevant disclosures.