More on Reimbursement

Anthem and American Medical Association announce new effort to streamline prior authorization process

One recommendation is to make prior authorization easier for providers that take part in risk-based contracts.

Susan Morse, Senior Editor

The American Medical Association and Anthem today announced  they will collaborate on solutions to streamline the prior authorization process to reduce the administrative burden and minimize delays and disruptions in care.

The first step is to eliminate low-value prior-authorization requirements, they said.

[Also: Major advocacy groups band together to streamline prior authorization]  

The idea was put forward earlier this year by the AMA, the American Hospital Association, America's Health Insurance Plans and other healthcare organizations in a consensus statement outlining ways to improve the prior authorization process. 

"The prior authorization process can be burdensome for all involved--healthcare providers, health plans, and patients," the consensus statement said. "Yet, there is wide variation in medical practice and adherence to evidence-based treatment. Communication and collaboration can improve stakeholder understanding of the functions and challenges associated with prior authorization …."  

Among areas for improvement include differentiating the application of prior authorization based on provider performance on quality measures and adherence to contractual, risk-sharing arrangements.

Another is for aligning prescribing patterns and ordering with historically high prior authorization approval rates. 

Regular review of the list of medical services and prescription drugs  can help to identify therapies that no longer warrant prior authorization due to, for example, low variation in utilization or low prior authorization denial rates. 

Regular review can also help identify new and emerging therapies in which prior authorization may be warranted due to a lack of evidence on effectiveness or safety concerns.

Clearinghouses and EHR and practice management system vendors, should develop and deploy software and processes that facilitate prior authorization automation using standard electronic transactions, the statement said.

These recommendations recognize that regulations addressing timeliness, continuity of care, and appeals are currently in place, including state and federal law and private accreditation standards.

"Collaboration between payers and healthcare professionals is critical in order to evolve and advance our healthcare system to one that is simpler, more accessible and more affordable for consumers," said Craig Samitt, MD, chief clinical officer at Anthem.

"Physicians caring for patients across the country have many ideas about how we can reduce healthcare costs and administrative burdens while improving clinical outcomes, and we need the collaboration of Anthem and all health plans to implement those strategies," said AMA Board Chair Gerald E. Harmon, MD.

Twitter: @SusanJMorse
Email the writer: