Medical Organization Coalition Calls for Prior Authorization Reform

AAFP Also Drafts Policy on Requirements

January 26, 2017 10:59 am Sheri Porter

Family physician Jennifer Aloff, M.D., has been taking care of patients in a five-physician practice in Midland, Mich., since 2001. But in recent years, practicing medicine has become more tedious.

A good deal of Aloff's angst is directly related to utilization management rules -- including prior authorization requirements -- devised and managed by health insurance companies.

"Dealing with the prior authorization process is the most frustrating aspect of my medical practice overall and has become increasingly time-consuming and complex," she told AAFP News in a recent interview. "In my office we now have a full-time staff person to deal with prior authorizations and referrals," she added.

Story Highlights
  • A coalition of medical organizations including the AAFP released 21 principles aimed at reforming prior authorization and utilization management requirements.
  • The coalition contends that bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources, and antagonized patients and physicians.
  • The AAFP also plans to release its own policy regarding prior authorization requirements by spring in response to a resolution adopted by the 2016 Congress of Delegates.

Physicians like Aloff will welcome news that changes that are underway aim to solve some of the underlying issues and make practicing medicine easier.

On Jan. 25, the AAFP and a coalition of 16 other medical organizations, including the AMA and the American Hospital Association, called for the reform of prior authorization and utilization management requirements that bog down physicians and impede patient care. 

A press release( bearing the names all of coalition participants announced the release of a document titled "Prior Authorization and Utilization Management Reform Principles."

According to the press release, members of the coalition agree that when health insurers require preapproval for medical tests, procedures, devices and drugs, patient care suffers.

"Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources, and antagonized patients and physicians alike," said AMA President Andrew W. Gurman, M.D., in the statement.

The coalition is "urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs."

The release highlighted responses from a recent physician survey that indicted the average medical practice completes some 37 prior authorization requirements per week, per physician, wasting some 16 hours of combined physician and staff time.

The survey also revealed that, of physicians surveyed,

  • 75 percent described their prior authorization burden as "high" or "extremely high,"
  • almost 60 percent waited at least one business day for prior authorization decisions,
  • more than 25 percent wait three business days or longer, and
  • nearly 90 percent said that prior authorizations sometimes, often or always delayed patient access to care.

Reform Principle Highlights

The 21 principles are divided into the following five categories:

Clinical validity specifies that utilization management programs be based on accurate and up-to-date clinical criteria that is readily available to physicians and never on cost alone. Such programs should include flexibility and the ability to override step therapy requirements as well as the appeal of prior authorization denials.

That appeal system should give the ordering physician direct access to another health care professional of the same specialty and with equal training to discuss medical necessity issues.

Continuity of care includes a provision calling for a minimum 60-day grace period for step therapy or prior authorization protocols for patients who are already stabilized on a treatment when enrolling in the health plan. During the grace period, the patient's medical treatment or drug regimen should not be interrupted while utilization management issues are addressed.

Furthermore, a drug or medical service that is removed from a plan's formulary or is subject to new coverage restrictions after the enrollment period has ended should be covered -- without restrictions -- for the rest of the benefit year. And patients must not be required to repeat step therapy protocols or retry therapies failed under other benefit plans.

Transparency and fairness principles ask utilization review entities to publicly disclose in an electronic format all patient-specific utilization requirements. In addition, accurate and up-to-date formularies need to be provided by such entities -- and displayed by vendors -- in electronic health records systems to, among other things, facilitate electronic prescribing.

Prior authorization approval and denial rates should also be made publicly available, and detailed explanations for denials should be made available and include the clinical rationale.

Timely access and administrative efficiency addresses the use of propriety health plan web-based portals that require physicians and other health care professionals to manage unique logins and passwords to each plan and manually re-enter patient and clinical data into the portal.

Also included in this section is language asking utilization review entities to refrain from revoking, limiting or restricting coverage for authorized care provided within 45 business days from the date the authorization was received. Providers should be notified of non-urgent care authorization determinations within 48 hours, and a determination for urgent care should be made within 24 hours after the receipt of necessary information.

Emergency care should never require pre-authorization.

This section also calls for standardization of criteria across the industry.

Alternatives and exemptions principles urge health plans to restrict utilization management programs to "outlier" providers; offer providers and practices at least one physician-driven, clinically based alternative program to prior authorizations; and exempt physicians participating in a "financial risk-sharing payment plan" from prior authorization and step therapy requirements for services covered under the plan's benefits.

Putting Patients First

Aloff represents the views of many family physicians when she says it's difficult to keep track of the myriad of requirements from multiple insurers with which a practice works. "This extends from prescribing medication to durable medical goods to ordering tests," she added.

Aloff pointed to erroneous or out-of-date medication formularies as a particular source of aggravation that often leads to calls from pharmacies and patients -- and interruptions in patient care.

"It is not uncommon for insurance companies to send a notice, usually via snail mail, that a prescribed medication is not on the formulary with instructions to 'please select a formulary alternative,'" said Aloff.

"They fail to provide a list of alternatives that are on the formulary so it leads to additional work and delay in tracking that down. Patients then are faced with the choice to either pay out-of-pocket for medication until authorization is received or delay getting medication and treatment."

Aloff recalled a recent instance where a prior authorization delay increased the cost of care when the patient opted to go to the emergency room for a CT scan because the insurance company mandated a 48-hour wait if the test was ordered as an outpatient. "There was no authorization required to order the test from ER," said Aloff.

She strongly supports the Academy's participation in the coalition. "The prior authorization challenges and frustrations we are facing are not unique to family medicine, and we should have a unified voice with our subspecialty colleagues to improve the process for all physicians and the patients they serve," she said.

Additional AAFP Action

In addition to its work with the coalition, the AAFP is developing its own policy on prior authorization requirements.

The creation of that policy is the direct result of a resolution adopted by the AAFP's 2016 Congress of Delegates that ultimately was referred to the Commission on Quality and Practice, a commission on which Aloff serves.

It was in that capacity that Aloff reviewed a draft document of the proposed Academy policy that will be presented to the full commission for discussion at its next meeting scheduled for Feb. 3-4 at Academy headquarters in Leawood, Kan.

Once finalized and approved, that policy will be officially released to the public. Stay tuned for more, as its release is anticipated by spring.

Related AAFP News Coverage
2016 Congress of Delegates
Family Physicians Intent on Fixing Issues That Impede Patient Care

Durable Medical Equipment, Prosthetics, Orthotics, Supplies
Final Rule Confirms Certain Items Will Require Prior Authorization

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2014 Congress of Delegates Resolution No. 305

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