Prior Authorization

Once just a burden, prior authorization has become a nightmare

Andis Robeznieks , Senior News Writer

Health plan prior-authorization processes have commonly been called burdensome, onerous, frustrating or pointless. But AMA President Jack Resneck Jr., MD, describes the hellish experience an insurance company put one of his patients through as “Kafkaesque,” which defines as “disorientingly and illogically complex in a surreal or nightmarish way.” 

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Dr. Resneck, a San Francisco dermatologist, was treating a patient who had “severe, head-to-toe eczema,” and because of that condition couldn’t sleep or work. Dr. Resneck found a targeted biologic medication that worked for the patient in a manner that was truly transformational and life changing, as he was able to sleep and return to work.

Everything was going great until, several months later, the patient was unable to get his prescription refilled at a pharmacy. Dr. Resneck diligently filled out the paperwork describing how well the patient had responded to the treatment and—as the insurance company required—faxed it over.

The prior-authorization request for the prescription refill was rejected.

“I was horrified,” Dr. Resneck said. “The reason it was rejected was that the patient no longer met the severity criteria. Not enough of his body was covered, he was not missing enough sleep. He wasn't itching enough. I was like: ‘Wait a minute. That means the drug is working!’”

It turns out the insurance company wanted to take the patient off the medication for several weeks to let his eczema flare up again.

“Just completely ridiculous,” Dr. Resneck said during the latest episode in the AMA Advocacy Insights Webinar Series. It took more than 20 additional telephone calls until he prevailed, and the patient’s prescription was refilled.

While the experience had a positive conclusion, Dr. Resneck noted that the time he spent battling the health plan was time he could have been spending with other patients.

Fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians.

Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Find out how the AMA is tackling prior authorization with research, practice resources and reform resources.

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The webinar described the status of federal and state prior-authorization reform efforts and the ongoing work of the AMA to rightsize the onerous process.

This included a discussion on the latest AMA prior-authorization physician survey (PDF) in which 94% of the 1,001 respondents said the process is associated with delays in care.

“These care delays aren't just inconveniences, they aren’t annoyances,” Heather McComas, PharmD, director of the AMA’s administrative simplification initiatives, said during the webinar.

“Our physicians are saying that prior-authorization care delays actually hurt patients: 80% of physicians reported that prior authorization can lead to patients completely abandoning a prescribed or ordered course of care,” McComas said. “Most alarming, one-third of physicians reported that prior authorization has led to a serious adverse event for a patient in their care. And a serious adverse event is something like hospitalization, permanent impairment or even death.” 

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1 in 3 doctors has seen prior auth lead to serious adverse event

Dr. Resneck noted that a recent government report finding that Medicare Advantage plans used prior authorization to delay or deny medically necessary treatment has also given momentum to federal reform efforts.

At the state level, previous reform efforts focused on streamlining or automating prior authorization. This has shifted to a concentration on lowering the volume of prior authorizations health plans require. The aim is to protect patients from delayed treatment or disrupted access to medications that have shown success in improving their chronic conditions.

“That's going to be really important as we anticipate a number of patients in the coming months transitioning off of Medicaid and into commercial plans,” Emily Carroll, senior legislative attorney for the AMA Advocacy Resource Center, said during the webinar.

The center is tracking prior authorization-reform bills in some 30 states, and Carroll described how the AMA helps reform efforts by providing model legislation, writing letters (PDF) to state officials and offering testimony in legislative hearings.

“Any state that has passed prior-authorization reform legislation will agree: Multistakeholder coalitions are key,” Carroll said. “States have done amazing jobs in assembling these prior authorization coalitions of patients, hospitals and pharmacists.”

The webinar panelists also noted the AMA’s support for a new prior-authorization rule from the Centers for Medicare & Medicaid Services that includes provisions requiring Medicare Advantage plans to ensure greater continuity of care, improve the clinical validity of prior authorization criteria, increase transparency of health plans’ prior-authorization processes and cut care disruptions due to prior-authorization requirements.

“I'm feeling the momentum on prior auth,” Dr. Resneck said. But “we’ve got a lot of work yet to do.”

Patients, physicians, and employers can learn about reform efforts and share personal experiences with prior authorization at