Major medical, insurance, health groups agree on pre-auth improvement areas


The prior authorization approval process required by health insurance companies for patients’ medical treatments, also called preapproval, eats up countless hours of time and costs, over $80,000 per year, per provider. The average provider deals with 35 of these prior authorization requests per day, and each request takes an average of 20 minutes. Physicians, pharmacists, hospitals, medical groups, and health insurance companies are working together to come up with a solution.

The American Hospital Association, America’s Health Insurance Plans, American Medical Association, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association announced a consensus statement delineating where they agree the health care industry can improve the prior authorization process.

Most of the solutions outlined in the document are intuitive – they include reducing the number of health care professionals subject to prior authorization requirements based on their performance; adherence to evidence-based medical practices or participation in a value-based agreement with the health insurance provider; reviewing the services and medications that require prior authorization and eliminating requirements for therapies that no longer warrant them; improving communications between health insurance providers, health care professionals, and patients to provide clarity on prior authorization requirements and changes; protecting continuity of care for patients; improving formulary information and coverage restrictions at point-of-care; and adopting national electronic standards for prior authorization.

Jack Resneck Jr., MD, chair-elect of the AMA board of trustees, described the document as a “good initial step” toward reducing the difficulties imposed by prior authorizations.

Prior authorization requests are particularly burdensome for medications that are expensive, a headache that doctors working with patients who have rheumatoid arthritis or lupus know well.

As insurance and provider groups work to improve the prior authorization process “it will be vital that they consider the issue from the perspective of general practitioners as well as specialists, the latter of whom prescribe more of the specialty tier medications that are subject to more protocols before patients can access these often life-improving medications,” Stephen Marmaras, director of policy and advocacy at Global Healthy Living Foundation, said in an interview. “Ultimately, improved communication between both parties – the physician offices and the payers – will allow us to identify barriers existing in current appeals processes and work toward collectively building solutions that benefit patients, particularly those with chronic disease who rely on stable access to medications.”

Sean Fahey, MD, chair of the American College of Rheumatology’s insurance subcommittee, said that, while the consensus statement is “a step in the right direction, like a lot of things, the devil is in the details.

“There’s good concepts in the statement without a whole lot of specifics,” Dr. Fahey said. Most changes will be addressed at the state level, because the federal legislature is very hesitant to legislate decisions for nongovernment insurance.

“A lot of the ideas set forth in this consensus statement are wonderful,” said Dr. Fahey. “Unfortunately for our patients, many of their medications are ludicrously expensive. … Every time you write a prescription for one of these medications, after appropriate therapy, you have to do [a preauthorization] just to get the medicine that people want and need. It’s frustrating that the issue of drug cost is driving the whole process. For a $60,000 a year price you’re going to have to do a preauthorization every single time, as opposed to a drug that’s $100 a year.”

Still, the statement is “an important step” toward ultimately making vital medications “more accessible for patients,” Dr. Fahey said.

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