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Payers, Providers Pledge to Improve Prior Authorizations

AHIP, BCBSA, AHA, and other organizations have agreed to improve the efficiency of prior authorizations.

Payers and provider organizations pledge to improve prior authorizations

Source: Thinkstock

By Thomas Beaton

- AHIP, BCBSA, AHA, and other leading payer and provider organizations announced an industry pledge to improve the efficiency of prior authorizations while reducing administrative burden.

Leaders of organizations participating in the pledge claim that aligning goals to improve prior authorizations can reduce the challenges of payers, providers, and other healthcare organizations face when managing high-cost prescriptions and medical devices.

“Prior authorization approvals can be burdensome for health care professionals, hospitals, health insurance providers, and patients because the processes vary and can be repetitive,” AHIP said in a press release.

“Streamlining approval processes will enhance patient access to timely, appropriate care and minimize potential disruptions. Enhanced transparency and communication also play critical roles in improving prior authorization processes, which underscores the importance of this new effort.”

Prior authorization requirements can be better targeted if they take into account provider performance measures, the organizations noted.

Providers have urged payers in recent months to streamline prior authorizations so patients can receive clinically valid prescription requests.

Reducing requirements for higher-quality providers may help avoid administrative burdens for providers that have demonstrated merit in prescribing practices via evidence-based guidelines, according to the consensus document. The organizations agreed to develop selective prior authorization programs by having providers help determine program criteria and adjust criteria for providers that participate in risk-based payment contracts.

The pledge also identifies an opportunity to improve prior authorizations through continual reviews of prescriptions and devices that require a prior authorization.

Prior authorization reviews should help determine whether certain devices and therapies no longer require a prior authorization or a new device/prescription lacks effectiveness or safety data. The organizations agreed to annually review of medical devices and prescriptions that require prior authorizations, encourage revision of prior authorization requirements using data analytics, and share changes regularly through provider websites and annual communication.

Additionally, participating payers and providers agreed that improving prior authorization information transparency and communication between stakeholders can help drive streamlined prior authorization processes.

“Effective, two-way communication channels between health plans, health care providers, and patients are necessary to ensure timely resolution of prior authorization requests to minimize care delays and clearly articulate prior authorization requirements, criteria, rationale, and program changes,” the organizations said.

Leaders among the payer and provider organizations plan to encourage greater transparency in prior authorization updates for patients and providers and improve timely notifications of prior authorization processes between health plans and providers.  

Prior authorizations can potentially disrupt a patient’s continuity of care, which the organizations agreed to address in their pledge.

Additional prior authorization changes are needed to make sure that formulary changes and other administrative burdens don’t impede a patient’s continuity of care, the pledge holds. These changes include reducing and minimizing repetitive prior authorization processes that impede continuity of care and adding patient protections from actions such as formulary and insurance benefit updates.

The last action item in the pledge is a commitment to use prior authorization technology to automate processes and add transparency in prior authorization information sharing.

“Additionally, making prior authorization requirements and other formulary information electronically accessible to health care providers at the point-of-care in electronic health records (EHRs) and pharmacy systems will improve process efficiencies, reduce time to treatment, and potentially result in fewer prior authorization requests because health care providers will have the coverage information they need when making treatment decisions,” the organizations said.

The organizations will encourage stakeholders to provide up-to-date information about prior authorizations to EHRs, pharmacy systems, and other electronic platforms to facilitate automation.

Likewise, the organizations will advocate for national adoption of electronic attachment standards to reduce burdens associated with prior authorization as well as work with vendors to develop optimized prior authorization technology.

Leaders within the organizations believe that an industry consensus is an important first step in improving prior authorization requests for all healthcare stakeholders.

“Working together, we can find the right solutions to improve the process, promote quality and affordable health care, and reduce unnecessary burden,” said AHIP Chief Medical Officer Richard Bankowitz, MD.

“By working together, we’re taking an important step forward in alleviating what can be an unnecessary burden for some patients, while ensuring our members continue to receive high quality, safe and effective care,” added Blue Cross Blue Shield Association Senior Vice President Justine Handelman. 


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