Prior Authorization Toolkit
Few phrases draw the ire of physicians and their staff more than “prior authorization” (PA). Given the long phone calls, tedious faxes and multitude of health plan portal logins/passwords that characterize the current PA process, the high level of physician frustration on this issue is hardly surprising.
PA is a health plan resource utilization control mechanism requiring providers to obtain advance approval before performing a service to qualify for payment coverage. While health plans may see PA as an effective tool to cut costs or ensure appropriate treatment, physicians experience PA as a manual, time-consuming process that questions their clinical judgment and siphons valuable resources away from patient care. Even more concerning are the treatment delays and negative patient health outcomes that can be caused by PA.
The AMA believes that PA is currently overused and that existing PA processes are extraordinarily burdensome. In order to help physician practices tackle the problems associated with PA, the AMA has created the following resources:
- PA Tip Guide: Given the fact that health plans will likely use PA as a utilization control tool for the foreseeable future, the AMA advocates for improved efficiencies in the PA process. This tip guide is designed to minimize the impact of PA on physician practices by reducing the number of “touches” required for PA and increasing the efficiency of PA workflows.
- Prior Authorization Toolkit: This extensive resource provides an overview of the current PA landscape, including a description of the status of PA automation; offer tips to help practices reduce the PA burden in the existing environment; and looks forward to the future of PA and the industry efforts and practice workflow changes needed to support a truly efficient PA process.
The National Committee on Vital and Health Statistics (NCVHS) is the federal agency with responsibility for the electronic health care transaction standards and other administrative simplification provisions contained within the Patient Protection and Affordable Care Act. AMA has provided the following testimony to NCVHS regarding the prior authorization process
June 16-17, 2015
February 26, 2015
- Joint presentation testimony of American Hospital Association, Medical Group Management Association, and AMA regarding operating rules for prior authorization.
February 19, 2014
- AMA presentation/testimony on pharmacy prior authorization.