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Prior authorization needs streamlining, new healthcare coalition including AMA, MGMA says

Group says it wants to improve timely access to care and reduce administrative burden.

Susan Morse, Senior Editor

The Medical Group Management Association and the American Medical Association are among many healthcare providers that have formed a coalition to ask health plans, benefit managers and others for a reduction in the administrative burden of getting prior authorization approval.

"Concerns that aggressive prior authorization programs place cost savings ahead of optimal care have led Delaware, Ohio and Virginia to recently join other states in passing strong patient protection legislation," the AMA said.

America's Health Insurance Plans said pre-authorization can ensure that patients are aware of treatments that may be as effective and less expensive than, for example, prescription drugs, where prices have skyrocketed.

[Also: Recondo rolls out prior authorization tool to automate process]

"This, in turn, can lower out-of-pocket costs for the patient immediately – and for all Americans in the long run," AHIP said. "It helps to increase care effectiveness and decrease costs. Patients benefit from better outcomes and better affordability."

The coalition of 17 healthcare organizations representing hospitals, medical groups, patients, pharmacists and physicians, is urging for reform in prior authorization requirements imposed on medical tests, procedures, devices and drugs.

They have developed recommendations for improving the process, releasing a set of 21 principles tackling five categories including clinical validity, continuity of care, transparency and fairness, timely access and administrative efficiency, and alternatives and exemptions.

"Health plan demands for prior approval for physician-ordered medical tests, clinical procedures, medications, and medical devices ceaselessly question the judgement of physicians, resulting in less time to treat patients and needlessly driving up administrative costs for medical groups," said MGMA President and CEO Halee Fischer-Wright. "Most importantly, despite the fact that the vast majority of prior authorization requests are ultimately approved, jumping through these administrative hoops can lead directly to delay or disruption in the delivery of care to the patient."

[Also: AHIP urges more flexibility in new value-based Medicare Advantage model]

Seventy-five percent of surveyed physicians described prior authorization burdens as high or extremely high, according to the AMA. More than a third of surveyed physicians reported having staff who work exclusively on prior authorization.

Nearly 60 percent of surveyed physicians reported that their practices wait, on average, at least one business day for prior authorization decisions, and more than 25 percent of physicians said they wait three business days or longer, according to the AMA.

"Nearly 90 percent of surveyed physicians reported that prior authorization sometimes, often, or always delays access to care," the AMA said.

Administrative burdens for both payers and physicians can be accomplished by reforming prior authorization and utilization management programs, the AMA said, in suggesting that both groups work together for a more efficient prior authorization process.

[Also: Patient experience, care access drive improvement efforts by medical practices]

Health plans have been working with providers and many others to find new ways to simplify the preauthorization process, AHIP said.

"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 said. "Health plans work with doctors and others to determine the best, most proven and most effective treatments for various conditions. This is particularly important when there are questions about efficacy of services, or where there is a wide variation in how to treat a particular ailment."

Coalition members include 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 Society of the State of New York, Minnesota Medical Association, North Carolina Medical Society, Ohio State Medical Society and Washington State Medical Society.

Twitter: @SusanJMorse

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