AHIP, BCBSA come to the defense of prior authorization as docs urge overhaul in MA

Doctor computer
Congress is taking a closer look at prior authorization, and major payer groups are defending the practice. (Getty/andrei_r)

As Congress takes a close look at prior authorization, payer groups are defending the practice, which they say is a crucial tool to prevent unneeded treatments and can control soaring healthcare costs. 

America’s Health Insurance Plans and the Blue Cross Blue Shield Association submitted comments to the House Committee on Small Business, which hosted a hearing on Wednesday with physicians to discuss the impacts of prior authorization on smaller practices. The two groups wrote (PDF) in their comments that their members are committed to streamlining prior authorization to ease the burden on doctors, but that it is one of the key tools they use for medication management, as such cannot simply go away.

“The purpose of the prior authorization is to demonstrate that the proposed treatment or procedure is truly indicated for that individual based on clinical evidence,” they wrote. 

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RELATED: 5 ways to streamline prior authorization, improve outcomes 

Prior authorization is a pain point for doctors across the health system, who argue that it delays care and piles additional administrative burden on their workloads. A survey from the American Medical Association released earlier this year found that 28% of docs believe prior authorization causes adverse events for patients

The hearing was held just days after 370 medical organizations—led by the Regulatory Relief Coalition and including groups such as the AMA and the Medical Group Management Association—urged legislators in a letter to reform prior authorization requirements in Medicare Advantage. 

A House bill aims to streamline prior authorization in MA. The healthcare groups backed that bill in the letter, as they say it would improve transparency and more effectively facilitate faster, electronic prior authorizations. 

In their submitted comments, AHIP said that based on stakeholder feedback the organization is undertaking to improve prior authorization and ease some of the struggles physicians face. For example, it's participating in tests alongside health technology companies and providers to automate parts of the prior authorization process. 

RELATED: Council of Affordable Quality Healthcare CORE updates rules for prior authorization 

BCBSA, meanwhile, is a member of the Payer to Provider Task Force, which was convened by the Department of Health and Human Services Office of the National Coordinator for Health IT to boost interoperability between providers and insurers. Through this group, BCBSA and other insurers have invested resources to make prior authorization simpler. 

“Both AHIP and BCBSA continue to actively engage with provider organizations to identify ways to improve prior authorization and other medical management tools to ensure patient safety, address the costs of healthcare and reduce administrative burden,” the groups said. 

Though it can be improved, both groups maintained that prior authorization is a key tool for their work in both private and public plans and is particularly effective in the wake of the opioid epidemic. 

Medication management ensures safe access to medication-assisted treatment and can flag unnecessary or overlong opioid prescriptions, they said. 

“AHIP and BCBSA urge the Committee to preserve the flexibility of private payers, medical groups taking on medical management functions and public programs to use these medical management tools to help ensure safe, effective and affordable care for patients,” they said. 

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