March 21, 2024- Prior authorization is the process by which physicians must obtain advance approval for a device, supply or medication from the patient’s insurance plan to ensure coverage for the recommended service, per the American Academy of Family Physicians. And it’s making family physicians – and a lot of other people – angry.
In 2018, five groups signed a “Consensus Statement” on improving prior authorization: the American Hospital Association, America’s Health Insurance Plans, American Medical Association, American Pharmacists Association, BlueCross BlueShield Association and the Medical Group Management Association. In their statement, the groups agreed to:
- Encourage the use of programs that selectively implement prior authorization requirements based on healthcare providers’ performance and adherence to evidence-based medicine. (Some call it a “gold card” system.)
- Encourage review of medical services and prescription drugs requiring prior authorization on at least an annual basis, with the input of healthcare providers.
- Improve communication channels among health plans, healthcare providers and patients; and encourage transparency and easy accessibility of prior authorization requirements, criteria, rationale, and program changes.
- Encourage sufficient protections for continuity of care during a transition period for patients when there is a formulary or treatment coverage change or change of health plan. (In other words, providers of patients on an approved course of treatment would not be required to go through the prior authorization process when that patient changes carriers.)
- Encourage healthcare providers, health systems, health plans, and pharmacy benefit managers to accelerate use of existing national standard transactions for electronic prior authorization.
Read More in the latest issue of JHC.