5 ways physicians, payers will work together to streamline prior authorizations

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Six leading health industry groups have joined in a commitment to improve prior authorization processes, (Getty/Martin Barraud)

Physicians and payers are vowing to collaborate to help relieve one of doctors’ biggest headaches: obtaining prior authorizations.

Six leading health industry groups, including the American Medical Association, the Medical Group Management Association and America’s Health Insurance Plans, have joined in a commitment to improve prior authorization processes, according to an announcement.

As a first step, they released a consensus statement (PDF) that outlines five steps for improvement.

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Other organizations joining in the effort are the American Hospital Association, American Pharmacists Association and Blue Cross Blue Shield Association.

Administrative tasks have placed more of a burden on physicians and obtaining prior authorizations for tests and treatments from payers is one of their leading productivity zappers. To help alleviate the burden, the groups have agreed to: 

1. Reduce the number of healthcare professionals subject to prior authorization requirements based on their performance, adherence to evidence-based medical practices or participation in a value-based agreement with the health insurance provider.

2. Review the services and medications that require prior authorization on a regular basis and eliminate requirements for therapies that no longer warrant them.

3. Improve communication between health insurance providers, healthcare professionals and patients to minimize delays in care and ensure clear prior authorization requirements, rationale and changes.

4. Protect the continuity of care for patients on an ongoing active treatment or a stable treatment regimen when there are changes in coverage, insurance providers or prior authorization requirements.

5. Accelerate industry adoption of national electronic standards for prior authorization and improve transparency of formulary information and coverage restrictions at the point-of-care.

“Working together, we can find the right solutions to improve the process, promote quality and affordable healthcare and reduce unnecessary burden,” said Richard Bankowitz, M.D., chief medical officer of AHIP, in a statement.

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“By forging an agreement addressing an important set of prior authorization challenges, this collaborative is leading the industry toward the dual aim of reducing the volume of required authorizations and decreasing complexity in conducting these transactions,” said Anders Gilberg, MGMA’s senior vice president, government affairs.

An MGMA poll last year revealed that 86% of respondents reported that prior authorization requests, as well as other requests from health insurers asking for physicians to provide supporting documentation on patients, had increased in the past year.

The MGMA was part of a 17-member coalition that put together 21 principles pushing for insurers to reform prior authorization processes to approve medical tests, procedures, devices and drugs for patients.