Provider groups ask payers for prior authorization reform

A total of 16 healthcare associations representing providers are calling on health insurers, benefit managers, utilization management firms and accreditation organizations to reform prior authorization processes that are invoked when physicians order tests, procedures, devices and drugs.

The organizations include: the American Academy of Child and Adolescent Psychiatry, American Academy of Dermatology, American Academy of Family Physicians, American College of Cardiology, American College of Rheumatology, American Hospital Association, American Pharmacists Association, American Society of Clinical Oncology, Arthritis Foundation, Colorado Medical Society, Medical Group Management Association, and AMA with affiliates Medical Society of the State of New York, Minnesota Medical Association, North Carolina Medical Society, Ohio State Medical Association and Washington State Medical Association.



The associations have compiled 21 principles that should be followed in determining prior authorization decisions. Several of the provisions involve the use of information technology—for example, requiring utilization review entities to publicly disclose in a searchable electronic format patient-specific utilization requirements such as prior authorization, step therapy and formulary restrictions with patient cost-sharing information, applied to individual drugs and medical services.

Also See: Taking the guesswork out of prior authorization

Other IT provisions cover utilization review entities providing and vendors displaying accurate patient-specific and up-to-date formularies that include prior authorization and step therapy requirements in electronic health records systems for purposes that include e-prescribing; and publishing prior authorization approval and denial rates on their web sites or other publicly available sites.

This information should include healthcare provider types and specialty; medication, test or procedure; indication; total annual prior authorization requests, approvals and denials; and reasons for denials and denials overturned upon appeal.

Three requirements are particularly important to physicians, says Robert Tennant, director of health information technology policy at the Medical Group Management Association. The first includes the public disclosure in electronic format of patient-specific requirements.

“Every time a doctor orders a service, device or drug, they have to contact a benefits manager or health plan, and it is burdensome,” Tennant contends. “This is the only HIPAA transaction that could actually impact care, as the doctor may not be able to take action for days or weeks. It’s a patient safety issue.

“We need a line in the sand with best practices to improve the process,” he continues. “A lot of it is just common sense. Prior authorization to run a CAT scan on an automobile accident victim should not be required.”

Also See: 8 trends affecting how physician practices will use IT in 2017

MGMA also is calling for consistency by health plans in setting courses of treatment. Insurers, Tennant says, each have their own interpretations of how long a specific course of therapy should be. One payer may offer 12 therapy visits for knee replacement patients, while others offer eight, 10 or 16 therapy visits. “it’s all over the map,” he adds. “A physician’s judgment should be relied upon if the physician has proven to be a good partner of the payer.”

The association has additional major concerns with two other principles. If a physician got approval for four weeks of therapy, the insurer should not come back two weeks later and ask that the physician again get preauthorization, Tennant says. And any utilization management should be based on up-to-date clinical criteria and never on cost alone.

The 21 principles of prior authorization reform are available here.