News & Commentary

Prior Authorization Overhaul Sought


Some heavy-hitting health care organizations think that the prior authorization process needs improvement, saying that it “can be burdensome for all involved—health care providers, health plans, and patients. Yet, there is wide variation in medical practice and adherence to evidence-based treatment.”

The consensus statement was issued earlier this year by the American Hospital Association, America’s Health Insurance Plans, American Medical Association, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association.

Meanwhile, CAQH CORE, a not-for-profit organization made up of over 130 public and private health plans, hospitals, vendors, and other stakeholders, says it supports the statement’s push for the adoption of a standard national prior authorization process. Such a process could save $6.84 per transaction, the organization says.

The group’s consensus letter encourages faster action by both providers and insurers regarding prior authorization. Health care providers, they say, should submit all the information necessary for prior authorization in a timely fashion, and insurers, for their part, should make their rulings faster.

“Effective two-way communication channels between health plans, health care providers, and patients are necessary to ensure timely resolution of prior authorization requests to minimize care delays and clearly articulate prior authorization requirements, criteria, rationale, and program changes,” the statement says.

There should be a regular review of just what medical services and prescription drugs should be subject to prior authorization based on low variation in utilization. “Regular review can also help identify services, particularly new and emerging therapies, where prior authorization may be warranted due to a lack of evidence on effectiveness or safety concerns,” the statement says.

Stakeholders should make the application for prior authorization based on performance on quality measures and adherence to evidence- based medicine. “Criteria for selective application of prior authorization requirements may include, for example, ­ordering/prescribing patterns that align with evidence-based guidelines and historically high prior authorization approval rates,” the statement says.

Technology can also help because part of the problem with prior authorization is the timing. The consensus statement urges that prior authorization requirements be accessible to providers at the point of care. The groups signing the statement also want to see “adoption of national standards for the electronic exchange of clinical documents (i.e., electronic attachment standards) to reduce administrative burdens associated with prior authorization.”

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