Payers, Providers Spar Over Proposed Prior Authorization Regulation

September 13, 2019 - America’s Health Insurance Plans (AHIP) and Blue Cross Blue Shield Association (BCBSA) joined together to defend prior authorizations in a statement submitted to the Committee on Small Business.

“Both AHIP and BCBSA continue to actively engage with provider organizations to identify ways to improve prior authorization and other care management tools to ensure patient safety, address the costs of healthcare and reduce administrative burden,” the organizations said in the statement.

The payers pointed to prior authorizations’ role in care management. Prior authorizations enforce best practices and guidelines for care management, AHIP and BCBSA said. They help physicians identify and avoid care techniques that would harm patient outcomes, such as designating prescriptions that could feed into an opioid addition.

From keeping track of medications to helping initiate important patient-provider conversations, prior authorizations can enable better, consistent patient outcomes and patient engagement, AHIP and BCBSA maintained.

Critics say that prior authorizations are arduous for providers and can lead to potentially dangerous delays in patient care access.

However, the health payers acknowledged that there are problems with the current prior authorization system. AHIP and BCBSA pointed to their efforts to collaborate with other industry players to establish a list of solutions. The payers committed to working with providers to protect patients’ information and physical as well as financial conditions, and streamline processes to ensure efficient access to care.

AHIP emphasized its role in bringing together vendors, payers, and providers to execute a demonstration project to test potential solutions.

BCBSA, which is a member of the Office of the National Coordinator’s (ONC) Payer to Provider Task Force, invested in federal prior authorization initiatives.

The payer organizations concluded with a call to action for Congress. AHIP and BCBSA asked that the committee permit the healthcare industry to continue to use prior authorization and care management tools.

The letter is in response to a bill currently in the House, an amendment to the Social Security Act that would limit use or prior authorizations.

Currently, the Social Security Act only loosely refers to prior authorization, stating simply that Medicare+Choice organizations have to disclose their prior authorization rules to Medicare Advantage members.

The amendment would add further parameters for Medicare Advantage plans’ use of prior authorizations.

In brief, the amendment forbids the use of additional prior authorizations when the plan does not require them for the procedure or when one has already been received. It instructs the HHS Secretary Alex Azar to define technology standards for prior authorization electronic transmissions. Lastly, the bill requires Medicare Advantage plans to review their prior authorization systems and submit data to the Secretary and online to the public.

This is not the first time AHIP and BCBSA have banded together to address prior authorization improvements, although last time there was a broader range of participants.

In January 2018, AHIP and BCBSA, as well as other major organizations from across the industry including the American Medical Association and the American Pharmacists Association, pledged to enhance and streamline prior authorizations.

The organizations agreed to align goals. The letter suggested instituting constant prescription and medical device reviews that require a prior authorization, increasing information transparency to make the process more efficient, and to automate processes with prior authorizations and heighten information sharing transparency.

On September 9, 2019, a separate letter to the Committee of Small Business supported the amendment on the grounds that it fulfilled the commitments made in the January 2018 pledge.

Signed by hundreds of patient, provider, and healthcare organizations, letter expressed that supporters of the amendment believed it would protect the growing number of Medicare Advantage enrollees and Medicare beneficiaries.

“This bipartisan legislation would help protect patients from unnecessary delays in care by streamlining and standardizing prior authorization under the Medicare Advantage program, providing much-needed oversight and transparency of health insurance for America’s seniors. We urge you to join your colleagues in supporting this important legislation.”

Once again on separate sides of policymaking, AHIP, BCBSA, and the provider organizations still agree that prior authorization is a valuable tool, but its processes need to be streamlined and more transparent.