Prior Authorization Process Needs Overhaul, Say Major Health Care Organizations

AHIP, AMA, MGMA and others offer recommendations on just how to improve the process.

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 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, saying that it could save $6.84 per transaction.  

The consensus letter by AHIP et al. encourages faster action by both providers and insurers regarding prior authorization. Health care providers 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. 

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. They urge that prior authorization requirements be accessible to providers at the point-of-care via electronic health records. They 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.”