Tue. Sep 27th, 2022

In 2018, the AMA, AHIP and other groups reached a mutual agreement on a number of steps to reduce the burden of prior authorization. How is that playing out?

Kate Berry: Our member health insurance providers have been very active in the time since that consensus statement in a number of areas. One example is that more insurers are waiving or reducing prior authorization requirements based on providers they’re working closely with in risk-based contracts or other alternative-payment models. … Another big example is leveraging electronic prior authorization, and we’ve done a lot there.

Dr. Jack Resneck Jr.: I think of it as the middle ground. There are a lot of things we would want to change about prior auth that weren’t in the agreement, so it seemed like a reasonable compromise when we sat down with insurers and said, “What are areas we can agree on, to rightsize this process?” … But when you look at what’s happened, none of the major insurers are operating according to that plan.

Some states have adopted “gold-card” bills, exempting certain providers from prior authorization based on their previous performance with approvals. What’s your organization’s position on these efforts?

Berry: Gold-carding can be good if it’s structured properly. We are not a proponent of mandated gold-carding. There have been some states—Texas is an example—where a gold-carding mandate passed. It’s quite broad and doesn’t allow for much in the way of accountability for ongoing performance. … If it’s structured properly, if it’s stratified based on provider performance and ongoing adherence to evidence-based medicine, it can work.

Resneck Jr.: We support them. And we’ve worked with partners in places like Texas and West Virginia, states that have adopted them, and there are a number of other states actively considering it. There’s another bill in Congress requiring it for Medicare Advantage plans. We want to see how they’re implemented by health plans, and that they don’t play games with this, but I think it has enormous potential.

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Could broader use of electronic prior authorization be one of the approaches to lessening the burden of prior authorization for providers and payers?

Berry: Yes, absolutely. We launched a project in January of 2020, what we call Fast PATH, which is just a clever name for the Fast Prior Authorization Technology Highway, our big demonstration project on electronic prior auth. We partnered with two different technology companies, one focused in the prescription medication area, and one focused on medical surgical services.

Resneck Jr.:It’s an important piece, yes. But I want to say that with some caveats. What does electronic prior auth mean? Is it efficient? If we still have prior auth required on way too many things, that now we’re just submitting them all electronically, and then having them rejected, and still having to do appeals, without actually fixing the underlying system and rightsizing it, that’s not enough.

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