The prior authorization process is coming under scrutiny at both the federal and state level.
Last week, legislation in the U.S. Senate was introduced that would create guideposts for the use of prior authorization in Medicare Advantage (MA) plans. And in Massachusetts, the Health Policy Commission (HPC) has included prior authorization among the topics it is investigating as part of its administrative simplification efforts. The HPC helped fund a study from NEHI this summer that proposed a series of steps to improve the prior authorization process. In addition, the Mass Health Data Consortium and its New England Healthcare Exchange Network (NEHEN) is piloting an automated process for prior authorizations.
Prior authorization (PA) is when a provider, on behalf of a patient, must request approval from the patient’s insurer before delivering a treatment or service. Insurers say PAs are necessary to make sure patients are getting the correct type of appropriate care and that care services are not overutilized, which drives up costs. Providers say the process often delays care, requires multiple administratively burdensome steps that vary from insurer to insurer, which leads to provider burnout and actually drives up costs.
Last week, Senators Roger Marshall (R-Kan.), Kyrsten Sinema (D-Ariz.), and John Thune (R-S.D.) introduced S. 3018, The Seniors' Timely Access to Care Act. It matches similar legislation (H.R. 3173) introduced in the U.S. House in May. The Seniors' Timely Access to Care Act would, among other things, establish an electronic prior authorization (ePA) program and require Medicare Advantage (MA) plans to adopt ePA capabilities; require the Secretary of Health and Human Services to establish a list of items and services eligible for real-time decisions under an MA ePA program; standardize and streamline the prior authorization process for routinely approved items and services, and ensure prior authorization requests are reviewed by qualified medical personnel.
In the commonwealth, the Massachusetts Health Data Consortium will be launching a standards-based, digital prior authorization prototype with one of Massachusetts' leading specialty hospitals and a leading insurer to automate prior authorization and reduce the administrative burdens imposed on patients and clinicians. Also in the Massachusetts, NEHI (Network for Excellence in Health Innovation) issued Streamlining Prior Authorization: Final Report & Recommendations
earlier this year. The report – funded by the HPC and the Mass Collaborative, of which MHA is a member – focused on four key issues: the frequency with which PA is applied; the variation among payers in services/pharmaceuticals subject to PA; the variation in PA criteria; and the variation in documentation required by payers to satisfy PA criteria. Among NEHI’s recommendations is one calling for a reduction in the number of PAs associated with treatments for extended courses of care, especially those associated with chronic conditions; and expanded use of “family codes.” NEHI wrote: “A reduction in administrative denials may be achieved by grouping like codes together in approving PA requests. Work to develop additional groupings will continue a number of reviews payers have already begun.”
To increase appropriate access to care and address the ongoing mental health crisis, language in MHA’s omnibus behavioral health bill (H.1061) would eliminate prior authorization for medically necessary mental health services and would put medical necessity determinations directly in the hands of the treating provider, similar to a measure passed in Massachusetts for substance use disorder in 2016.
MHA’s Senior Director of Managed Care Karen Granoff said, “We look forward to collaborating with other key stakeholders to advance the recommendations made in the NEHI report and to addressing the challenges providers and patients face as a result of prior authorization requirements.”