Inconsistent rules for prior authorization of claims. Varying rules across state lines.  Long waits.  What’s going on with prior authorization in healthcare?  We take a look at delays, frustrations, and proposed solutions.

Prior Authorization methods at hospitals are changing

What’s the solution for smart prior authorization at your hospital?

“Sometimes, health plans deny reasonable prior-authorization requests for evidence-based treatments and instead send back ‘suggested alternatives’ that are completely inappropriate for the disease being treated,” Dr. Resneck, chair-elect of the AMA Board of Trustees, told AMA Wire®.  “We also now have to submit prior-auth requests for many patients who are already stable on a therapy when their health plan suddenly changes the rules.”

MD Mag seconds the idea that the system has some major flaws, identifying differing policies as part of the problem:  “An examination of Medicaid prior authorization policies for medication treatment of attention-deficit/hyperactivity disorder (ADHD) finds policies are inconsistent across states, which could influence whether treatments are consistent with, or differ from recommended practices.”

Oddly, even though the hold-ups and bottlenecks occur regardless of submission method, at least one company touts electronic submissions as part of the answer.  “Electronic prior authorization (ePA) may be able to provide physicians with a faster, more streamlined method to ensure patients are treated with the most cost-effective and appropriate therapy,” according to a press release from Express Scripts.

Streamlining sounds good, but doing so electronically is just part of the puzzle.  No amount of electronic speed can get you by regulations and the folks that administrate them.  An article in Health Payer Intelligence suggests that “Payers can increase the efficiency of a prescription drug prior authorization by reducing unnecessary regulations and implementing electronic prior authorization protocols.”

The insurance industry is also pushing for more automated solutions.  A survey conducted by SureScripts and published by AHIP (America’s Health Insurance Plans) found that a third of providers’ prior authorization orders are delayed by two days. The report suggested that prior authorization delays can occur less frequently when the process leverages automated technologies.

We took a look at that survey and see that they did uncover very real frustrations on the part of physicians:  “The survey uncovered that providers are extremely frustrated with the cumbersome manual prior authorization process. Physicians are annoyed that it takes ‘multiple phone calls for each prior authorization’ and ‘it ties my nurse up on the phone and pulls her away from clinical duties.’ Their case for a solution is summed up in one sentence in the published report:  “Compared to the current manual prior authorization process, the time required for prescription approvals goes from days to minutes.”

Greater speed for prior authorization… problem solved?  Not so fast.  MedicalXPress reports one hold-up that goes beyond simply speed of application.  “A rare glimpse into the prior authorization requirements implemented by public and private insurance providers across the country has found substantial administrative burden for a new class of medications for patients with high cholesterol that places them at high risk for heart attack or stroke, according to new research from the Perelman School of Medicine at the University of Pennsylvania.”

Solutions to the prior authorization puzzle

WLRN.org gives details on one legislative solution to the pre-authorization bottlenecks at the human level.  “Doctors would have greater leeway in prescribing medications to patients – and insurance companies would have less time to approve prior-authorization requests under a bill proposed by a lawmaker from Sarasota. Republican Senator Greg Steube said he’s advocating on behalf of doctors who are struggling to properly treat their patients.”

Still another legislative solution has been enacted, this time in South Dakota.  HME News reports that “on Jan. 1, South Dakota’s Medicaid program began requiring prior authorizations for most mobility devices, as is the case for Medicaid programs in most states and for Medicare in a number of states. But South Dakota will also require prior authorizations for repairs or replacement of parts or accessories.”

What’s the final prior authorization (PA) solution?  Probably a combination of smart electronic submissions and a continued push to speed up policy decisions.  As AMA-ASSN.org reports, “in 2016, an AMA survey measured the burden created by PA requests and the impact on timely patient care. Supported by these data, the AMA and 16 other health care and patient associations released a set of 21 principles in January 2017 to guide reform of PA and utilization-management requirements.”  That set of principles included identification of “five opportunities for improving the prior authorization process.”  The five opportunities are:

  1. Selective application of prior authorization
  2. PA program review and volume adjustment
  3. Improved transparency and communication regarding PA
  4. Protections for continuity of patient care
  5. Automation to improve transparency and efficiency of PA requirements and processes

For its part, the AHIP has also worked to generate a list of prior authorization solutions.  In a press release from January of 2018, the organization in collaboration with collaboration, the American Hospital Association (AHA), American Medical Association (AMA), American Pharmacists Association (APhA), Blue Cross Blue Shield Association (BCBSA) and Medical Group Management Association (MGMA) recommends these steps be taken:

  • Reduce 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 review the services and medications that require prior authorization and eliminate requirements for therapies that no longer warrant them.
  • Improve channels of communications between health insurance providers, healthcare professionals, and patients to minimize care delays and ensure clarity on prior authorization requirements, rationale, and changes.
  • Protect 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.
  • Accelerate industry adoption of national electronic standards for prior authorization and improve transparency of formulary information and coverage restrictions at the point-of-care.