Inefficient payer approval processes fail patients, frustrate docs
Prior authorization. Preauthorization. Prior approval. Pre-approval. No matter what you call it, these “utilization management” schemes that consume more and more of urologists' days can be redesigned to make them more relevant and more efficient. This is demonstrated by recent attempts to simplify the administrative burden via state law, as well as a set of principles laid out by the American Medical Association and a coalition of physicians, medical groups, hospitals, pharmacists, and patients.
“Preauthorization has escalated beyond reason,” according to AACU President Charles McWilliams, MD. “The list of services that require approval seemingly gets longer every few months. My staff spends at least 30 to 60 minutes for every surgery and medication preauthorization.”
According to a December 2016 survey of 1,000 physicians conducted by the AMA, 90% of respondents reported that the prior authorization process delays access to necessary care. AACU Health Policy Chair Jeffrey Frankel, MD, said, “Prior authorizations are very disruptive to patient care and have, in a big way, allowed insurance companies to practice medicine without a license.”
The AMA survey found that 80% of physicians are “sometimes, often, or always required to repeat [prior authorization] requests for prescriptions when the patient has already been stabilized on a treatment for a chronic condition.”
“I received such a notice this past August for a patient who had been on the same medication for bone metastases from solid tumors since June 2015,” Dr. Frankel reported. “The insurer subsequently approved coverage, but now wants to assign a penalty of 20% of the drug's cost for 'retro' prior authorization.”
Twenty-six percent of physicians in the AMA survey said that, “in the prior week, they waited 3 business days or more on average to receive prior authorization decisions from health plans.
“The entire process needs to be streamlined,” Dr. Frankel said. “In Washington state, a workgroup is looking at a mandated short response time of 2 to 3 days, after which the drug ordered is filled.”
Likewise, in several state legislatures, bills are being considered to foster greater efficiency. A proposal in the Georgia House of Representatives would apply already enacted prior authorization requirements to pharmacy benefit managers (PBMs), including a 48-hour response mandate (GA HB 35). Florida insurers and PBMs would have to respond to non-urgent requests within 3 days if legislation under consideration in both the state House and Senate becomes law (FL HB 877/SB 530). To protect physicians from exposure to liability, a lawmaker in Hawaii authored a bill specifying that insurers, not health care providers, are liable for civil damages caused by undue delays for prior authorization (HI HB 885).