The Headache of Prior Authorization

The challenges of obtaining prior authorizations are further compounded by staffing shortages and a tightened labor market.

For proposed rule 87 FR 3475, the Office of the National Coordinator for Health IT (ONC) of the U.S. Department of Health and Human Services (HHS) published a request for information to determine the need to improve the prior authorization process for medical services.

Last week, the comment period for Electronic Prior Authorization Standards, Implementation Specifications, and Certification Criteria ended.

For the purposes of this request for information, prior authorization generally refers to rules imposed by healthcare payers requiring that approval for a medication, procedure, device, or other medical service be obtained prior to payment for the item or service. Prior authorization requirements are established by payers to help control costs and ensure payment accuracy by verifying that an item or service is medically necessary, meets coverage criteria, and is consistent with standards of care.

Stakeholders have stated that diverse payer policies, provider workflow challenges, and technical barriers create an environment in which the prior authorization process is a source of burden for patients, providers, and payers, and also a contributing cause of burnout for providers (and a health risk for patients, when it delays their care).

ONC’s Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs,released in 2020, identified challenges associated with the prior authorization process, including: a) difficulty in determining whether an item or service requires prior authorization; b) difficulty in determining payer-specific prior authorization requirements for those items and services; c) inefficient use of provider and staff time to navigate communications channels such as fax, telephone, and various web portals; and d) unpredictable and lengthy amounts of time needed to receive payer decisions.

In order to address these issues, the ONC Strategy Team included a number of recommendations to strengthen electronic prior authorization processes, such as leveraging health IT to standardize data and processes used when ordering services or equipment; coordinating efforts to advance new standards approaches; and incentivizing adoption and/or use of technology that can generate and exchange standardized data to support documentation needs.

The ONC Health IT Certification Program could also incorporate standards, implementation specifications, and certification criteria to advance electronic prior authorization. A recent March 2022 poll taken by the Medical Group Management Association (MGMA) found that prior authorization requirements have increased in the past 12 months, causing delays in patient care and increased time spent by medical practice staff.

The challenges of obtaining prior authorizations are further compounded by staffing shortages and a tightened labor market.

In an open letter to the ONC, MGMA stated that “rising prior authorization requirements and the burdens associated with them have long been a pervasive challenge for medical groups trying to focus their time and resources on treating patients. MGMA believes that developing a national standard for electronic prior authorization (ePA) and the supporting electronic attachments would make the PA process more efficient and ultimately benefit patients, as well as drive down administrative burden and cost for providers.”

Although advancing an ePA standardization is critical to achieving automation and improving efficiency, there still is a need to regularly review medical services and prescription drugs that are subject to prior authorization requirements – and to adjust the volume of these accordingly. This should be done at the ONC level, not the for-profit payer level.

Additionally, transparency, communication, and interoperability regarding prior authorizations is lacking. To minimize patient care delays, effective communication between health plans and medical groups is critical. Unfortunately, prior authorization is often completed via fax, telephone, mail, or online proprietary payer portals, and consists of different medical necessity requirements across payers.

These differing requirements, with no standardization – many of which change suddenly, without adequate notice to practices – and the inconsistencies and manual nature of the process result in inefficient communication and delays in patient care.

Larger reform must support continuity of care for medical services and medications for patients.

MGMA believes that ePA has the potential to decrease administrative burden through automation, but only if implemented properly. Without addressing broader reform, automation could simply increase the incidence of prior authorization. Unless the ONC steps in, there is a possibility that automating prior authorizations could lead to health plans unnecessarily expanding their application, both in terms of volume and requirements, thereby negating the desired benefits of ePA.

The ONC needs to consider ways to align ePA standards with payment and QPP (Quality Reporting Programs), but with ensuring that there are adequate guardrails in place to keep payers from manipulating the spirit of the intent for across-the-board standardization of prior authorizations.

The whole point is for standardization, less burden, and to get patients the care they need, without the burden of cumbersome prior authorizations.

Programming Note: Listen to Terry Fletcher today as she reports this story live during Talk Ten Tuesdays, 10 Eastern.