Sustainability

What your state can do to fix prior authorization run amok

A rheumatologist last year diagnosed Middleton, Pennsylvania, teenager Zachary Souders with juvenile idiopathic arthritis and prescribed adalimumab (marketed as Humira) to treat it.

The Food and Drug Administration approved the injectable anti-inflammatory drug for use in treating the condition in 2008, yet the Souders family’s two health insurers hemmed and hawed about covering the medication that could ease the chronic pain Zachary had been living with for months.

Zachary’s mother, Laura Souders, called the insurers every day for nearly a month without success in her bid to secure prior authorization for the drug. Souders finally took an afternoon off work and spent three hours on the phone with an insurance company representative to clear the prior-authorization hurdle, she told the Pennsylvania Medical Society (PAMED).

Souders cannot help but ponder the fate of patients and families less able to navigate the maze of prior authorization.

“If I had this much trouble getting prior auth, how do people get through this system when they’re elderly, or don’t have the computer skills, or aren’t as persistent as I was?” she said.

It is a question to which too many physicians know the distressing answer: patients just give up. An AMA survey of 1,000 practicing physicians found that payers’ prior-authorization (PA) requirements delay treatment, have a negative impact on clinical outcomes and lead patients to abandon treatment.

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The vast majority of physicians surveyed—92 percent—said patients whose treatment requires PA experience care delays sometimes, often or always.

Make transparency, timeliness the law

PAMED has been asking patients to share their stories about how insurance company prior authorization processes have delayed their care. PAMED, in turn, has been sharing those stories in an effort to build support for a bill to reform health plans’ prior-authorization practices.

State medical societies looking to get their legislatures to address PA don’t have to start from scratch. Legislators in Pennsylvania and other states have crafted their own bills using model legislation drafted by the AMA as a foundation.

The AMA’s  model bill, the “Ensuring Transparency in Prior Authorization Act,” is designed to make the PA process timelier and less opaque.

The purpose for the legislation is spelled out clearly, and it cites a need to guard against PA programs that attempt to place “cost savings ahead of optimal patient care.”

The model bill would require that the health plan or “utilization review entity” post online their current PA requirements and restrictions, including clinical criteria.

Statistics on PA approvals and denials for medications, procedures or diagnostic tests would have to be posted for each medical specialty. Also, reasons for denial and statistics on what procedures most often trigger the PA process would have to be made available.

Under the model bill, PA determinations would have to be made within two working days for non-urgent care and within one business day for urgent care. No PA requirements would be allowed for emergency care.

Also, if—after emergency care is delivered—immediate post-evaluation or post-stabilization services are needed, a determination must be made within 60 minutes of the request. If utilization reviewers don’t make a determination within 60 minutes, “such services shall be deemed approved,” the model bill states.

Other provisions include a ban on retroactively denying authorization or payment within 45 days after receiving approval. The bill also requires insurers to accept and respond to standard electronic PA transactions for prescription medications and makes clear that faxes, proprietary payer portals and electronic forms shall not be considered electronic transmission.

The AMA Advocacy Resource Center has developed a chart that summarizes individual state laws for PA timeliness, transparency and electronic transmission.

Earlier this year, the AMA joined with other stakeholders—including the insurance industry trade group America’s Health Insurance Plans and the Blue Cross Blue Shield Association—to issue a consensus statement on prior authorization that encourages “transparency and easy accessibility of prior authorization requirements, criteria, rationale and program changes.”

Through the Physicians Grassroots Network and the Patients Action Network, the AMA is giving physicians and patients a way to share their experiences with prior authorization and add their voices to advocacy for reform.