Industry groups take aim at speeding the prior authorization process
National electronic standards are expected to play an important role in an industrywide effort to streamline the process of communicating prior authorizations for treatment.
Groups representing hospitals, physicians, medical groups, health insurers and pharmacists have announced an effort to improve often-lengthy prior authorization processes—also known as pre-approvals—that slow the delivery of treatment to patients.
Facilitating the prior authorization process also is expected to provide benefits to the healthcare industry, participants in the initiative say—it could reduce administrative burdens for healthcare professionals, hospitals and health insurers.
Typically, if a treatment or prescription requires prior authorization, it must be approved by a health insurer before it’s administered. However, these approvals can be burdensome for all parties because the processes vary and often are repetitive. Streamlining can reduce the number of steps and time delays.
The new collaboration includes:
• The American Hospital Association
• America’s Health Insurance Plans
• American Medical Association
• American Pharmacists Association
• Blue Cross Blue Shield Association
• Medical Group Management Association
The groups have signed a consensus statement, pledging to work together on a variety of initiatives. In particular, the organizations are committing to accelerating industry adoption of national electronic standards for prior authorization and improving the transparency of formulary information and coverage restrictions at the point of care.
In addition, the organizations say they will seek to improve communication between health insurers, healthcare professionals and patients to minimize delays in care and ensure clarity on prior authorization requirements, rationale and changes.
In addition, the organizations are pledging to collaborate on:
• Reducing the number of healthcare professionals subject to prior authorization requirements based on their performance, adherence to evidence-based medical practices or participation in a value-based agreement with the health insurance provider.
• Regularly reviewing the services and medications that require prior authorization and eliminate requirements for therapies that no longer warrant them.
• Protecting continuity of care for patients who are on an ongoing, active treatment or a stable treatment regimen when there are changes in coverage, health insurance providers or prior authorization requirements.
“These principles provide a good starting point for providers and health plans to work together toward continuous improvement in quality of care and health outcomes while reducing unnecessary administrative burden,” said Tom Nickels, executive vice president of the AHA.
“This collaboration among healthcare professionals and health plans represents a good initial step toward reducing prior authorization burdens for all industry stakeholders and ensuring patients have timely access to optimal care and treatment,” said AMA Chair-elect Jack Resneck, Jr., MD.
Prior authorization is generally a highly manual process, although some processes have been automated. For example, the National Council for Prescription Drug Programs offers a standard for electronic prior authorization for electronic prescriptions. The NCPDP standard supports the process of determining if a PA is needed, requesting and communicating PA approval and appeals.