Health-Care Groups Streamlining Prior Authorization

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By Sara Hansard

Health-care provider and insurer groups have agreed to work together to streamline prior approvals for medical treatments.

Groups representing physicians, pharmacists, hospitals, health insurers, and medical group managers will work on improving the prior authorization process, they said in a Jan. 17 consensus statement. “The prior authorization process can be burdensome for all involved,” they said. “Yet, there is wide variation in medical practice and adherence to evidence-based treatment.”

Difficulty in getting prior approvals for medical treatments has long been a source of contention between medical providers and patients, on one side, and health insurers, who argue that prior approvals are needed to reduce unnecessary, overly expensive treatments. Collaboration between the groups is a step toward making the health-care system more efficient and effective.

Could Be Used For Government Guidance

The consensus statement is voluntary, but the agreement could be used by the federal government as guidance that would be more binding, Robert Tennant, director of health information technology with the Medical Group Management Association (MGMA), told Bloomberg Law Jan. 17. The 40,000-member MGMA, which represents physician practice administrators, is one of the organizations that agreed to the consensus statement.

“The vast majority of prior authorizations are ultimately approved,” Tennant said. “But the hoops that practices and hospitals and pharmacists have to jump through are tremendous.”

The American Hospital Association (AHA), the American Medical Association (AMA), America’s Health Insurance Plans (AHIP), the Blue Cross Blue Shield Association (BCBSA), and the American Pharmacists Association (APhA) also agreed to the consensus statement.

Insurers: : A `First Step’

“I would say this is a first step,” Richard Bankowitz, chief medical officer of AHIP, told Bloomberg Law Jan. 17. “It’s a step that creates a shared understanding of the problem.”

Prior authorizations for medical procedures such as surgeries and for medications are used by health plans to make sure care is safe, evidence-based, and affordable, Bankowitz said. “There continues to be a lot of variation in the way care is practiced. Not all of the care is evidence-based.”

The consensus statement won’t necessarily lead to changes in agreements between health plans, doctors, and hospitals, Bankowitz said. Individual health plans will implement the consensus principles in ways where they can make the biggest progress, he said.

There isn’t a timeline for implementing the consensus statement, Bankowitz said. “As we develop more concrete plans I think the timeline will emerge from that.”

First Principles Released in 2017

The AMA released a set of principles in January 2017 with 16 other associations representing medical groups, hospitals, pharmacists, and patients. The principles were intended to reduce administrative burdens associated with prior authorizations and to ensure that patients receive timely care that is necessary, according to background information provided by the AMA to Bloomberg Law in an email Jan. 17.

That led to discussions with health insurers and the development of the consensus statement, the AMA said. “While individual health plans will be determining the specific criteria and implementation strategies for improving their prior authorization programs and processes, the consensus statement recommends the involvement of clinicians who are contracted with the health plans, as well as organizations representing physicians, pharmacists, medical groups and hospitals,” it said.

The consensus statement, which was agreed to in December and released Jan. 17, calls for selectively implementing prior authorization requirements based on health care providers’ adherence to evidence-based medicine, among other things. It also calls for protecting continuity of care for patients when there are changes in drug formularies or health plan coverage. In addition, it calls for industry-wide adoption of electronic prior authorization transactions based on existing national standards.

`Low-Hanging Fruit’

Organizations that are part of the consensus statement made a commitment “to look at areas where there is more low-hanging fruit,” Anne Burns, vice president of professional affairs for the APhA, told Bloomberg Law Jan. 17.

Specific decisions haven’t been made about which areas will be worked on first, Burns said. However, “A potential area of focus could be more around the prior authorization processes for medications,” she said.

Carl Schmid, deputy executive director of The AIDS Institute, a public policy organization that focuses on human immunodeficiency virus/acquired immunodeficiency syndrome and other serious chronic conditions, welcomed the announcement. “We have to see its implementation to make sure that patients get the drugs that providers prescribe,” he said.

But, Schmid said, “This is great news for patients and providers.”

To contact the reporter on this story: Sara Hansard in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at

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