Medical groups cheer legislation that aims to aid prior auths

Eight medical specialty societies are supporting newly introduced legislation in the House of Representatives to ease the prior authorization process for patients and caregivers.

Prior authorization has been a bane for clinicians, because the process for obtaining approval from health insurers can be lengthy. For example, Medicare Advantage plans require physicians get advance approval before providing services, and physicians contend that insurers are using prior authorization indiscriminately, leading to treatment delays or outright denials to cover care.

The Improving Seniors’ Timely Access to Care Act, (HR 3107), is backed by four legislators, including Susan Delbene (D-Calif.), Mike Kelly (R-Pa.), Rodger Marshall, MD (R-Kan.) and Ami Bera, MD (D-Calif.).

The legislation was introduced by the Regulatory Relief Coalition, comprising associations representing physicians, hospitals and health plans. The bill would require the Centers for Medicare and Medicaid Services to regulate how Medicare Advantage plans can use prior authorization.

Also See: AMA hits insurers for slow progress in cutting prior authorizations

Under the bill, Medicare Advantage plans also would report on their use of prior authorization and the rate of approvals or denials by service or prescribed medication.

“For more than two years, the Regulatory Relief Coalition made it our responsibility to chip away at barriers that deny our patients timely access to medically necessary care, and the walls enabling prior authorization’s abuse are about to come down,” says George Williams, MD, president of the American Academy of Ophthalmology.

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A recent physician survey found that nearly 90 percent of responding doctors report prior authorization as having a negative impact on outcomes; a third of patients abandon their treatment because of prior authorization; stable patients have been asked by their health plan to switch medications with no medical reason to do so; and physicians can get as many as 40 prior authorization requests weekly.

“With the Improving Seniors’ Timely Access to Care Act, a strong bipartisan group of elected officials in Congress are saying enough is enough, care delay is care denied, and America’s seniors deserve the care that they expect from the Medicare program,” says Ann Stroink, MD, chair of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons Washington Committee.

Robert Tennant, health information technology policy director at the Medical Group Management Association, says the proposed legislation is a ground-breaking bill because prior authorization is the leading challenge to physicians because of the administrative burdens that authorization imposes on clinicians.

“It takes doctors away from the patient and (puts them) on the phone with insurance companies, so it actually affects patient care,” he contends.

A large reason for that is because 20 years after creation of the prior authorization standard under HIPAA, the Centers for Medicare and Medicaid Services has yet to finalize the electronic prior authorization standard, and only about 12 percent of physicians are using some sort of electronic form to conduct the authorizations—primarily via faxes and payer portals—while most just keep using manual processes.

“Without the standard, you can’t really use the prior authorization transaction,” Tennant says. Asked why the standard has not been finalized, he adds, “Nobody knows—if that’s the only thing this bill does, it would be critically important. Even insurers want it.”

So if a patient goes to an outpatient setting for a colonoscopy, ideally he or she may have a polyp removed, and a prior authorization will get approved, and the patient goes home, Tennant explains. But that’s not what typically happens because the insurer may require a separate authorization, resulting in the patient being sent back home to come back the next day when the separate authorization has been approved.

What’s needed, according to MGMA, is better transparency on the use of prior authorizations. No one really knows how many authorizations are required and approved, so the legislation seeks answers.

“The next step is to gin up interest on Capitol Hill,” Tennant concludes. “We hope this is one of those no-brainer bills that will sail through, as there is high consensus of the need.”

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