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    Inefficient payer approval processes fail patients, frustrate docs


    Five broad rules for proper care

    Clinical validity. This includes concepts such as utilization management (UM) criteria being based on up-to-date clinical reasoning and never costs alone. This exemplifies the need for patient-specific concerns and flexibility.

    Continuity of care. This rule ensures that patient care is not disrupted by prior-authorization requirements. During review for authorization, any medical treatment should not be interrupted while the UM requirements are addressed.

    Transparency and fairness. This rule addresses the need for detailed clinical explanations for denials and transparency of all restrictions in a searchable, electronic format. Patient-specific electronic health records can further good reform.

    Timely access and administrative efficiency. This rule establishes adequate response times for UM decisions and seeks health plans' acceptance of electronic prior authorizations. Reliability is important between the insurer and their physicians and patients.

    Alternatives and exemptions. If necessary for certain cases, this rule asks that health plans come with an alternative to prior authorization. Contracts to participate in a financial risk-sharing payment plan should be exempt from prior authorization and step-therapy requirements for services covered under the plan's benefits.

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