Major organizations aim to change prior authorization requirements

A coalition of medical organizations led by the American Medical Association (AMA) has released a 21-point plan to change when health insurers require pre-approval before patients can receive certain treatments, drugs or devices.

Some state efforts have resulted in nationwide changes at certain insurers, like when New York’s attorney general reached a settlement with Anthem to end the requirement for pre-approval for medication-assisted opioid addiction treatment. These groups want to go further, arguing the entire spectrum of preauthorization standards needs to be reevaluated.

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources and antagonized patients and physicians alike,” AMA President Andrew Gurman, MD, said in a statement. “The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs.”

Besides the effects on care delivery, the AMA press release said current practices waste time. According to their own survey, practice complete an average of 37 prior authorizations per physician every week, taking an average of 16 hours out of every five business days. A large majority of doctors (75 percent) said those standards are a burden on their practices, with more than a third saying they have a staff member dedicated solely to prior authorization.

The 21 principles listed by the coalition are grouped in five broader categories: clinical validity, continuity of care, transparency and fairness, timely access and administrative efficiency, alternatives and exemptions.

Some of the more specific principles include:

• Any utilization management program applied to a service, device or drug should be based on accurate and up-to-date clinical criteria and never cost alone, with the clinical references readily available.
• Utilization review entities should offer a minimum of a 60-day grace period for any step therapy or prior authorization protocols for patients who are already stabilized on a particular treatment upon enrollment in a health plan.
• Eligibility and all other medical policy coverage determinations should be performed as part of the prior authorization process. Patients and physicians should be able to rely on an authorization as a commitment to coverage and payment of the corresponding claim.
• Prior authorization should never be required for emergency care.

You can read the full list of principles here.

The coalition is made of the AMA and 16 other groups: 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, Medical Society of the State of New York, Minnesota Medical Association, North Carolina Medical Society, Ohio State Medical Association and Washington State Medical Association.