Could This Finally end the Struggle with Prior Authorization!

There is no doubt prior authorization regulations have negatively impacted almost every specialty starting from behavioral health and rheumatology to radiology and cardiology.

According to an American Medical Association (AMA) survey, “An average physician practice completes 45 prior authorizations per physician, per week, and doctors and their staff spend nearly two business days a week completing such authorizations.” But now as the medical community continues to advocate for improved patient care and reduced administrative burdens, the issue of obtaining approvals has again taken center stage.

In an effort to address the time-wasting and care-delaying practices associated with pre-auth, an increasing number of states are considering legislative reforms with nearly 90 prior-authorization reform bills being considered in 30 states, with several still pending.

Most of the bills are based on the AMA’s model legislation and aim for the reforms to include some key components.

Key Components of Prior Authorization Reform Bills

1. Establishing Quick Response Times

Recognizing the urgency of certain medical situations, prior authorization reforms advocate for the establishment of prompt response times from payers (24 hours for care requiring urgent delivery, and 48 hours for non-urgent kinds).

2. Involvement of Specialized Physicians

To ensure that decisions regarding pre-auth align with the specific needs of the patient, the proposed reforms call for adverse determinations to be made only by physicians licensed in the state and specializing in the relevant field.

3. Prohibiting Retroactive Denials

Under the proposed reforms, retroactive denials of authorized care would be prohibited. Once care is preauthorized, the payer would not be able to retroactively deny coverage, thereby providing certainty to both physicians and patients.

4. Extended Validity Periods

To reduce administrative burdens, prior authorizations would be valid for a minimum of one year, regardless of any dose changes that may occur during the course of treatment. For patients with chronic conditions, the reforms recommend that the pre-authorization remain valid for the entire duration of the treatment.

5. Transparency and Accountability

Transparency and accountability play a vital role in ensuring fair and efficient prior-auth processes. The proposed reforms advocate for the public release of insurers’ pre-authorization data, including information on approvals, denials, appeals, and wait times.

6. Continuity of Care

Recognizing the importance of continuity of care, the reforms require new health plans to honor a patient’s authorization for at least 90 days.

7. Reducing Volume through Innovative Solutions

The proposed reforms also explore innovative solutions to reduce the volume of pre-authorizations and may involve implementing prior authorization exemptions for certain services or implementing gold-carding programs, which grant automatic authorization based on predetermined criteria.

Main Objectives to Reform Prior Authorization

The main objectives that these prior authorization reform bills seek to accomplish are as follows:

  • To set clear timelines allowing physicians to make timely decisions and provide optimal care to their patients.
  • To ensure that the physician reviewing the case possesses the necessary expertise to make informed decisions.
  • To put an end to retroactive denials to allow patients and providers to be certain about costs and coverage.
  • To reduce administrative burdens through the establishment of an authorization validity window.
  • To increase transparency and accountability to enable patients, physicians and policymakers better understand the shortcomings of the current system.
  • To prevent unnecessary disruptions in ongoing treatments and allow patients to maintain the stability of their care plans.

Final Thoughts

The movement to reform pre-auth requirements is gaining traction. Recently, the Centers for Medicare and Medicaid Services (CMS) also made regulatory changes to align Medicare Advantage plans’ PA requirements with Fee-for-Service Medicare.

While there is significantly more interest and urgency this time, to reform pre-auth requirements, it remains to be seen if a prior authorization legislation addressing all the key concerns will be passed in the near future.

Irrespective of the outcome, Sunknowledge Services Inc., a trusted HIPAA-compliant healthcare revenue cycle company, will continue to support US healthcare providers by accurately completing various healthcare administrative tasks like getting prior authorizations, like they have been doing for almost two decades now.

For queries on prior authorization regulations, guidelines or updates, please feel free to reach out to Sunknowledge Services Inc.