The American Medical Association, American Hospital Association and 14 other healthcare organizations have joined forces to make it easier to adhere to prior authorization requirements imposed on providers.
The coalition, announced Wednesday, will lobby health plans to streamline prior authorization for medical tests, procedures, devices and drugs. They say the current process is time consuming and can negatively affect patient care.
The organizations together drafted 21 principles for health plans to use to reform their prior authorization requirements.
“Our hope is to build a dialogue between providers, health plans and their third parties so we can cut out needless administrative waste from the system,” said Rob Tennant, health information technology policy director at the Medical Group Management Association, which is part of the coalition.
Tennant said the coalition hopes to work with America's Health Insurance Plans and individual private insurers to make reforms.
The principles focus on five broad categories: clinical validity; continuity of care; transparency and fairness; timely access and administrative efficiency; and alternatives and exemptions.
One principle recommends insurers' prior authorizations policies only apply to services, drugs or devices based on clinical criteria instead of costs. Another principle states prior authorization forms should be detailed and indicate if any necessary information is missing.
Most of the principles outlined by the coalition are “common sense,” Tennant said.
In response to the coalition, Kristine Grow, a spokeswoman for AHIP said, “Health plans have been working with providers and many others to find new ways to simplify the pre-authorization process. This work has resulted in a better understanding on what information is needed for prior authorization, as well as to provide the groundwork for national standards for electronic prescribing processes.”
AHIP has been part of discussions with health plans and physicians over the last decade to reduce the paperwork and administrative burdens associated with prior authorizations.
But physicians continue to report they are burdened by the requirement.
Seventy-five percent of practicing physicians reported prior authorization is a high burden for themselves and their staff, according to a December 2016 survey of 1,000 physicians conducted by the AMA. About 22% of physicians reported their staff members spent more than 20 hours per week processing prior authorization requirements.
Insurers argue that prior authorizations are necessary because they “help ensure patients receive the most effective and efficient care, AHIP's Grow said.
Prior authorization can curtail the effects of high drug prices, for example, because it can ensure patients are aware of other treatments that may be less expensive but are just as effective, Grow said.
But Tennant at MGMA said the vast majority of services requested through prior authorizations are approved. “This is clearly a money issue,” he said.
Prior authorization can also sometimes delay or interrupt necessary care for patients, said Dr. Jennifer Aloff, a family medicine physician with a practice in Midland, Mich., and a member of the commission on practice and quality at the American Academy of Family Physicians, which is part of the coalition.
Aloff said health plans often don't inform her if a drug requires prior authorization so a patient is sometimes told at the pharmacy the treatment isn't covered by their insurance, delaying care. Many of the principles outlined by the coalition focus on transparency, urging health plans to share treatments that require prior authorization with providers.
“The biggest concern is prior-authorization hinders the patient's access to care and delays treatment,” Aloff said
The coalition members also include: the American Academy of Child and Adolescent Psychiatry; American Academy of Dermatology; American College of Cardiology; American College of Rheumatology; American Pharmacists Association; American Society of Clinical Oncology; Arthritis Foundation; Colorado Medical Society; Medical Society of the State of New York; Minnesota Medical Association; North Carolina Medical Society; Ohio State Medical Society; and Washington State Medical Society.