Addressing Unnecessary Prior Authorization Practices



What if I told you that despite the passage of the Affordable Care Act and all the tweaks and reforms that have followed, right now, across the country, specialists like me are finding that once they and their patients decide on a treatment plan, the insurance company usually must pre-approve the treatment or test, or it won’t pay for it?

Pre-authorization (also called prior authorization or precertification) is the latest tactic health insurance companies use to limit the services they provide for their customers. In essence, it’s a crude way to reduce costs by delaying or not approving planned, non-emergency (elective) surgery for patients who need it.

The inefficiency and lack of transparency associated with prior authorization are costly, and these requirements consume an enormous amount of physician offices’ time. More importantly, however, these complex processes can have negative consequences for patient outcomes when treatments are delayed or denied altogether.

The process for obtaining this approval is lengthy and typically requires physician office staff to send multiple faxes and make numerous phone calls to get the health plan to approve the recommended tests, treatments or prescription medications. Additionally, after many attempts, these requests are often rejected, and neurosurgeons like me are forced to engage in a process called “peer-to-peer” review, where they must speak to another physician — who may or may not be a neurosurgeon — to discuss the treatment plan. What’s worse is that after weeks of effort, the health plan often ultimately approves the test or procedure, demonstrating that this whole time-consuming process was totally unnecessary.

Restricting abusive prior authorization tactics is a top issue for the Alliance of Specialty Medicine, a coalition of national medical specialty societies representing more than 100,000 specialty physicians. We are actively engaging in advocacy efforts to reduce the burdens of prior authorization practices for Medicare Advantage and other health plans so our patients can have timely access to care.

To this end, we were very encouraged to see Reps. Phil Roe, MD, (R-Tenn.) and Ami Bera, MD, (D-Calif.) spearhead a letter to their colleagues in the U.S. House of Representatives urging the Centers for Medicare and Medicaid Services to improve how prior authorization works under MA. Signed by 103 bipartisan House members, the letter to CMS Administrator Seema Verma notes, “Patients may be encountering barriers to timely access to care that are caused by onerous and often unnecessary prior authorization requirements.” It goes on to urge CMS to do the following:

— Issue guidance to MA plans to dissuade the widespread use of prior authorization and to provide direction to the health plans to increase transparency, streamline prior authorization and minimize the impact on patients;

— Ensure that these requirements do not create inappropriate barriers to care for Medicare patients;

— Collect data on the scope of prior authorization practices — including denial, delay and approval rates.

Neurosurgeons like me take care of very sick patients who suffer from painful and life-threatening neurologic conditions such as brain tumors, debilitating degenerative spine disorders, stroke and Parkinson’s disease. Without timely medical care, our patients often face permanent neurologic damage, and sometimes death.

The Roe-Bera letter is a good first step in addressing unnecessary prior authorization, and we commend these legislative leaders for their efforts, but more needs to be done. The time is now for CMS and other health plans to rethink the entire prior authorization process for the betterment of our patients.

Alex B. Valadka, MD, FAANS, FACS, is the chairman of the Department of Neurosurgery at Virginia Commonwealth University School of Medicine and serves as spokesperson for the Alliance of Specialty Medicine, a coalition of national medical societies representing more than 100,000 specialty physicians in the United States.

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