Groups press insurers to reform prior authorization

Doctor with computer and gadgets
A coalition of healthcare organizations is pushing insurers to reform prior authorization processes.

A coalition that includes leading physician groups is pushing for insurers to reform prior authorization processes to approve medical tests, procedures, devices and drugs for patients.

The coalition, made up of 17 healthcare provider organizations, says the way insurers currently handle preapprovals creates unreasonable hurdles for patients seeking care. It urged health plans, benefit managers and others to reform current requirements, and released new principles (pdf) it says would improve timely access to care and reduce administrative burdens.

For instance, the coalition wants to see providers receive a decision from insurers for non-urgent care within 48 hours and for urgent care within 24 hours of receiving all the necessary information. It also wants utilization management programs to be based on accurate and up-to-date clinical criteria that are available to providers and the public.

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited healthcare resources and antagonized patients and physicians alike,” American Medical Association President Andrew Gurman, M.D., said in an announcement. The groups want to see insurers and others apply those reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs, he said.

The time that doctors and clinicians spend on data entry and administrative tasks associated with prior authorization takes away from patients, according to the AMA, which cited its recent survey that showed medical practices complete an average of 37 prior authorizations per physician each week, which takes about 16 hours to process. The survey also found 75% of physicians described prior authorization burdens as high or extremely high, and more than a third said they have staff who work exclusively on prior authorizations.

The Medical Group Management Association said while the vast majority of prior authorization requests are ultimately approved, doctors and other clinicians must jump through administrative hoops that can delay or disrupt patient care. “Health plan demands for prior approval for physician-ordered medical tests, clinical procedures, medications and medical devices ceaselessly question the judgment of physicians, resulting in less time to treat patients and needlessly driving up administrative costs for medical groups,” said the group’s president and CEO, Halee Fischer-Wright, M.D.

The coalition says requiring preapproval by insurers before patients can get certain drugs or treatments can delay or interrupt medical services, divert significant resources from patient care and complicate medical decisions. Those concerns have led Delaware, Ohio and Virginia to recently join other states in passing strong patient protection legislation, according to the AMA statement.