Physicians Push for Prior Authorization Reform Efforts

Leigh Page


January 23, 2019

Seeking a 'High-Value Experience' for All

Physicians are definitely making efforts to reform the prior authorization process.

In January 2018, the American Medical Association (AMA) and other clinician organizations signed a joint consensus statement that set out a number of reforms.[1] The statement was signed by two trade organizations representing payers: America's Health Insurance Plans and the Blue Cross Blue Shield Association.

In March, the AMA and Anthem announced that they would work together to identify solutions that "drive a high-value experience for patients, physicians, other healthcare professionals and health plans" in many areas, including prior authorization.[2]

Insurers have "come to the table" to work with physicians on prior authorization reform, Jack Resneck, then chair-elect of the AMA, told AMA Wire in April.

"We're working with them to reduce the number of treatments subjected to prior authorization, exempt those physicians who demonstrate high approval rates, improve transparency of requirements, protect patients who are already on treatment, and make submission of [prior authorization] requests easier," he said.[3]

The 2018 consensus statement called for the following reforms:

Remove drugs with low denial rates. Payers should regularly review services under prior authorization and remove drugs that show "low variation in utilization or low prior authorization denial rates," the statement read.

Since then, some individual plans have made some commitments in this regard:

  • In Anthem's March statement with the AMA, the insurer said it was beginning to "streamline or eliminate low-value prior authorization requirements."

  • In Pennsylvania, Highmark's senior medical director said the plan considering paring back its list of services requiring prior authorization. "If those services are approved the majority of the time, why bother everybody with it?" he said.[4]

Exempt physicians with high compliance rates. Exemptions from prior authorization might be given to physicians with "prescribing patterns that meet evidence-based guidelines and physicians with high prior authorization approval rates," the consensus statement said.

In an individual statement without the other organizations, the AMA suggested that exemptions should be handed out to "physicians using approved, clinically based appropriate use criteria and clinical decision support."[5]

However, this suggestion has met with opposition from some in the insurance industry. Exempting certain physicians wouldn't work because no physician has a perfect record, wrote Lee N. Newcomer, MD, a senior vice president at UnitedHealthcare, in a statement released in July.[6]

He pointed to a study he authored on oncology prior authorizations, which showed that "even the most compliant practices had errors, and a single error resulting in a payment denial causes a significant financial loss for the practice and the payer," he wrote.

Make rules accessible. Payers should "encourage transparency and easy accessibility of prior authorization requirements, criteria, rationale, and program changes," the consensus statement read.

In addition, plans should release changes in prior authorization rules in a timely manner, according to an AMA attorney speaking before the American Academy of Family Physicians (AAFP). The AMA attorney added that insurers should notify practices at least 60 days before any change to prior authorization policies takes effect.[7]

Make authorization rulings timely. There should be "timely notification of prior authorization determinations by health plans," the consensus statement said.

The statement did not call for specifics, but the AMA attorney told the AAFP meeting that the deadline should be 1 business day for urgent care and 2 business days for nonurgent care.

Support continuity of care. Payers should "minimize disruptions in needed treatment," including "minimizing repetitive prior authorization requirements," the consensus statement read.

"Continuity of patient care is vitally important for patients undergoing an active course of treatment when there is a formulary or treatment coverage change and/or a change of health plan," the statement explained.

Continue to automate the process. This should include adoption of national standards for transmission of clinical documents, according to the statement.

The AMA has encouraged physicians to tell payers that they want these changes. Keeping up pressure for reforms also means lobbying for bills in state legislatures and Congress to control prior authorization.

In addition to the 11 states requiring some form of prior authorization, 17 states have passed legislation calling for standard application forms for all payers, according to the AMA's state-by-state list. (Interestingly, having standard forms was not mentioned in the consensus statement.)

Some states have passed very specific restrictions. For example, a New Mexico bill signed into law in March 2018 puts restrictions on step therapy, a type of prior authorization where you must first try a less expensive drug before prescribing one that is more expensive.[8]

In other states, however, legislators have been resisting physicians' reform efforts. For example, "Pennsylvania continues to struggle with [prior authorization] legislation," an oncologist in the state wrote in a publication of the American Society of Clinical Oncology in August."[9]


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