State and federal policymakers have been taking actions recommended by the AMA to help ensure patients have timely access to affordable care during the COVID-19 pandemic. These include suspending or reforming prior authorization (PA) processes. Now, private insurers—including Medicare Advantage (MA) and Medicaid managed care plans—are following suit.
While these actions are welcomed, PA policy changes among private payers vary widely and are rapidly evolving. These changes may be applied differently in individual states, and may differ between commercial, MA and Medicaid plans. PA reform has been a top AMA priority. To help physicians sort through the complexity, the AMA has created a resource that summarizes the PA policy modifications made by major national health plans in response to the COVID-19 crisis. The tool is updated frequently as companies announce their PA policy changes.
Common changes to utilization-management policies enacted by commercial insurers during the COVID-19 public health emergency include:
- Temporarily waiving PA for COVID-19 testing and treatment.
- Suspending PA for patient transfers to less-intensive care settings.
- Extending PA duration for elective procedures that will be rescheduled.
Adding to the complexity, however, is that individual plans have different termination dates for when some of these temporary adjustments are set to expire. This is particularly true for extensions of existing PAs and whether the PA was for facility admission, prescription medications or elective procedures or elective outpatient services.
One payer notes it will not deny claims for failure to secure a required PA if the care was emergent, urgent or involved “extenuating circumstances,” explaining COVID-19 qualified as such a circumstance the same way as any natural catastrophe such as a hurricane, tornado or fire.
Some plans’ PA requirement changes only apply to in-network providers, further complicating the intricate policy landscape.
The resource also notes whether plans have changed PA requirements related to durable medical equipment and lists changes to prescription drug plan PA policies.
Many of the PA program adjustments implemented by commercial plans align with AMA state policy recommendations developed as responses to COVID-19. The AMA continues to advocate on behalf of physicians and their patients for policymakers to take quick action on prior authorization to prevent delays in care and wasted resources during the pandemic.
Physicians can stay up to date on all of the AMA’s COVID-19 advocacy efforts and track the fast-moving pandemic with the AMA's COVID-19 resource center, which offers a library of the most current resources from JAMA Network™, the Centers for Disease Control and Prevention, and the World Health Organization.