News From Our Perspective

Navigate the Healthcare System with Ease

Mar 2017

Are the Days of Prior Authorization Coming to an End?

A recent American Medical Association survey found doctor practices reported submitting an average of 37 prior authorization requests each week with an average of 16 hours of physician and staff time to complete. That is two full days each week of well-trained physicians playing the “Mother May I” game with commercial health plans.

The AMA surveyed its members on this issue at the end of 2016.

“Prior authorization is a huge issue,” said Heather McComas, senior policy analyst at the American Medical Association (AMA). “We hear about this issue all the time from our [physician] members. Even more than that is the patient impact; they see that care can get delayed by this process and it really upsets them.”

There was a brief moment many years ago when health plan United Healthcare briefly flirted with the idea of eliminating prior authorizations. The idea has recently found new life in the healthcare community. Effective January 1, 2017, United Healthcare began piloting a program that eliminates prior authorization requirements for 20 of 29 services for eligible Medicare Advantage members. Could this just be the start of a new trend in healthcare that would be welcome news to physician practices across the country?

“Studies have shown that prior authorization is the biggest ‘pain point’ among providers,” said Pam Jodock, a senior director of healthcare business solutions at HIMSS. “The issue is not automation; it’s the business processes to which automation would be applied.”

The AMA survey found, “75 percent of respondents found prior authorization to be quite burdensome, and over a third reported having staff that work exclusively on prior authorization.”

The AMA convened a prior authorization reform work group to discuss the issue. The association is also partnering with the University of Southern California in Los Angeles on a project to look at the costs associated with prior authorization as well as how it is impacting patients.

Proactive health plans are coming up with their own solutions to simplify the process. But do not think health insurance companies are doing their own studies out of the goodness of their hearts. It is simply because health payors realize  there are great administrative costs tied into the authorization requirements, from front-end, full-time employees to back-end staff handling the appeals and legal battles with providers.

Blue Cross and Blue Shield of Louisiana have plans to introduce an online-authorization portal which will allow providers to enter their own authorization information. This process will allow providers to receive instant notification if their procedure is approved. BlueCross BlueShield of Western New York announced earlier this year that the plan will lift the prior authorization requirement for 212 services, meaning doctors and patients will no longer need the insurer’s approval in those cases.

One other organization working on the authorization issue is the Healthcare Administrative Technology Association (HATA), a group of 33 businesses including practice management software vendors, value-added vendors, clearinghouses and associations representing vendor clients.

There are also small steps in eliminating the authorization red-tape in certain medical cases. New York’s Attorney General Eric Schneiderman reached settlements with two major healthcare payers, Cigna in October 2016 and Anthem in January of this year, to eliminate lengthy prior authorization processes to ensure opioid use disorder patients receive timely treatment. The American Medical Association (AMA) recently called on attorney generals across the nation to follow in New York’s footsteps with reforming prior authorization requirements for medication-assisted treatment for opioid abuse.

Our Partners Have a Combined Legal Experience of Over 100 Years

Meet our experts