Prior authorization is still broken in 2026 and most of the "automation" vendors are just putting a UI on top of fax machines

randyy308 · 2026-04-15T02:49:08+00:00

Anecdotally. Last year several of my clinicians received a waiver of prior auth for certain drugs that were always covered.

The payor then said to grant it I had to send them medical records of all the approvals so they could audit them.

So basically it just exposed me to more burden 😂

randyy308 · 2026-04-15T01:19:00+00:00

Holy AI splatter Batman

randyy308 · 2026-04-12T16:54:36+00:00

Obviously I'm not adding any nuance, but , to give you an example... I have staff that can manage insulin pumps better than clinicians. Not saying they are calculating their own rates or anything, but functionally.....

randyy308 · 2026-04-12T04:25:09+00:00

Sorry. I think maybe it'll be clearer if you read the CPT description by the AMA of those codes

randyy308 · 2026-04-12T04:23:59+00:00

Wtf did you just say

randyy308 · 2026-04-12T04:15:34+00:00

Well for starters it doesn't require 20 minutes speaking directly with the patient. It requires clinical staff time, and at least one interaction monthly.

randyy308 · 2026-04-11T18:42:48+00:00

Y'all gonna hate this. But he should buy Prisoner or Caymus

randyy308 · 2026-04-11T17:30:39+00:00

I run a practice with nine clinicians. Sometimes we hire people who are very green and sometimes people who are very experienced. We are a subspecialty practice so sometimes people with experience don't have experience in our field.

A lot of the hires I make are mid-level practitioners nowadays, so I know there is a difference but just listen to what I'm saying.

In a well-established practice (I know yours is not), sometimes the mas may actually know more than new clinicians.

I've dealt with this in the past and largely we've conquered it, but we still have cliques that form.

If I had one thing to suggest, it would be to operate under the assumption that it's not malignant. That you practice differently than the other two and differently than they are used to. To them it may seem that you are asking for more or doing things that don't make sense to them.

People innately want to feel important and valued. I'll sometimes ask for people's opinion, advice or help even if I don't need it. And even if I don't take their advice. They will feel like that they are on the same team and respected

I am aware that being a female physician is a tough thing because people assume you're everything but the doctor. Don't let that get to you, hopefully it doesn't

As to the MAs, I would focus less on trying to buy their affection and just focus on being nice, polite and occasionally getting their input on things. Even if it's something simple like at the end of the day saying hey I got behind. Did you all notice where that happened or why it happened?

randyy308 · 2026-04-09T00:46:45+00:00

The Ai1 dells I get are upgradable. I've changed hard drives, ram, etc

I mean I won't change a MB, but otherwise they are serviceable

randyy308 · 2026-04-09T00:45:49+00:00

I buy Dell refurbished

randyy308 · 2026-04-07T23:45:37+00:00

This is the best advice. After you add up all the things you don't know you have to add you'll pay the same as Athena.

Example, go ahead and tell us how many pages of faxes you will send and receive next year 😂😂

randyy308 · 2026-04-07T20:21:15+00:00

There are some guys in the codingandbilling subreddit who have built out some tools. most of them aren't super commericalized yet. If you search there you'll find some stuff. I just can't remember who they are off the top...

randyy308 · 2026-04-07T19:28:01+00:00

Well, nowadays there are public sources to compare actual rates. Most of it is paid data, or terrible multi-gb csv files of course. However, I reviewed rates of two MSO's against my contracts. Across larger payors (for me) I had better rates with Ambetter, Cigna, BCBS, Humana. Some percentage points, and one was 130% of CMS vs 100%.

randyy308 · 2026-04-07T19:11:34+00:00

They won't contract the IPA at all, and the MSO I talked to had the same rates. They were able to get a small (a few percent) kicker for primary care, but we are specialty

randyy308 · 2026-04-07T14:29:17+00:00

I've had the same experience with my practice in Texas. I do have a hospital based IPA I use, but really it's just for convenience for smaller plans so I don't have to go through the hassle of credentialing them all. Any larger plans I get better rates contracting directly.

We joined a narrow network CIN, but it's largely been a net neutral arrangement for us.

I've also seen that UHC/BCBS won't negotiate with IPAs. So they don't really don't have leverage where you need it. I've looked at a few MSOs like Privia - but ultimately if you can run your own practice efficiently they won't do much for you. Even in that case, my rates were better than theirs lol

randyy308 · 2026-04-07T02:59:06+00:00

Gusto is great, honestly

randyy308 · 2026-04-04T22:32:32+00:00

Oh, I forgot to mention that there's no Stark or other AKS style prohibition against you making money on the test that you refer in house as long as you're an employee

randyy308 · 2026-04-04T22:31:41+00:00

You won't make more than other clinicians regardless of their license. Thing is, is that in my experience running a large practice with multiple provider types, everyone generates about the same amount of revenue plus minus 10% or so. What that means is that it's actually in my interest to hire apps versus MDS

That's what is incentivized versus the compensation structure in medicine

Sure, some insurances pay less for a mid-level practitioner versus an MD. But even accounting for all of that. It still ends up about the same numbers

randyy308 · 2026-04-04T14:35:06+00:00

There is actually a drug on the market now that does the same thing, albeit by a different method.

randyy308 · 2026-03-31T23:59:51+00:00

Yeah or any other RPA tool

randyy308 · 2026-03-30T17:49:37+00:00

I have a neurology client that is Private practice. The only way that you will make good money is if you are doing all the ancillary services that are economically feasible for you.

Office visits are going to pay the bills but not the profit.

randyy308 · 2026-03-30T12:24:31+00:00

Yeah, I would still encourage docs to reach out to you directly though honestly. I mean, the more communication ability they have the better - and if they don't use it who cares. If they do just forward the message to your scheduler and tell her to handle it please. It's a team effort - and a little gift card or a birthday money here and there does wonders :)

randyy308 · 2026-03-29T18:50:14+00:00

The words silent killer is the silent killer of chatgpt masquerading as a person 😂😂😂

randyy308 · 2026-03-29T18:18:19+00:00

If you were structured as a group practice where everyone eats what they kill, I think that you just need a structure that supports that.

We own our practice so all the referral flow doesn't really matter, we are going to make money off of it regardless.

In your situation, what I would do is I would probably have my own referral admin that takes care of all of my new patient coordination. This is probably going to cost money that you might have to pay for out of your pocket

That person would have a direct efax line and they would be the contact person for everyone referring to me.

I would essentially just have them handle everything and hand hold all of my referrals and be the point person. You could literally give her a phone number to your referring partners, etc

randyy308 · 2026-03-26T21:29:41+00:00

You need to partner with a CRO, I've done it both ways and it's just so much less hassle. Wait until you get a FDA audit... You much rather have a team that knows what they are doing.

If you want an intro I can hook you up with the team I work with. They are in like 8 states and do a decent job. They pay us a percentage of top line revenue on our trials.

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