Fixing prior auth: These critical changes must be made

The time-wasting, care-delaying, insurance company cost-control process known as prior authorization has gone from a rarely employed tool to discourage use of extremely pricey interventions to a form of utilization management that can be required for even the simplest generic medication.

Insurance companies’ overuse of prior authorization is causing patients real harm – in some instances even resulting in death. One-third of the 1,001 physicians the AMA surveyed (PDF) reported that prior authorization has led to a serious adverse event for a patient in their care, including 9% that said prior auth led to a patient’s disability or permanent bodily damage, congenital anomaly or birth defect or death.

Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Find out how the AMA is tackling prior authorization with research, practice tools and reform resources.

An AMA model bill (PDF) can help physicians get started on advocating change in their own state legislatures. Explore the collection of in-depth articles below to learn more about the reforms that are needed, how the AMA is pushing for change, and what progress is being made.

1. First, speed up payers’ response times

   1. AMA survey data shows that 94% of physicians reported that prior authorization can delay patient care. When the Arthritis Foundation surveyed more than 3,000 patients, it found that three days was the average wait time for prior authorization. However, 31% of respondents said they had waited more than a week for an answer.
   2. The delays result in unnecessary pain, the worsening of patients’ illnesses and in some cases even death. Federal and state lawmakers and regulators need to enact policy changes to ensure that patients and physicians get timely answers to prior authorization requests.

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      5 positive signs on the road to fixing prior authorization

2. Hack away at the volume of prior authorizations required

   1. When it began decades ago, prior authorization was used sparingly as a way for insurers to determine if costly medical procedures or medications were needed. Today, prior authorization has deteriorated into a system that requires physicians to get the OK to prescribe even the most routine medications and procedures. It’s often even required for medications that a patient has been on for years to manage an illness and for chemotherapies known to be the only effective treatments for a particular cancer—a circumstance when timely treatment is particularly important.
   2. “When I prescribe a medication, I would say 95% of the time, I have to obtain a prior authorization. We have four full-time employees who their sole focus is on obtaining prior authorization for medications to treat Crohn’s disease and ulcerative colitis. And that’s for just one disease state,” Bethesda, Maryland, gastroenterologist Jessica Korman, MD, told The New York Times in an opinion video that was recently posted: “‘What’s My Life Worth?’ The Big Business of Denying Medical Care.”
   3. In a week, an average practice now completes 45 prior authorizations, per physician. That’s far too many. The AMA supports eliminating prior authorization requirements for regularly approved care, gold-carding programs that allow physicians who routinely have their requests approved to no longer have to get prior auth for that care and for no longer requiring that certain medications must go through a prior authorization process.

3. Give doctors a true peer to talk with—stat

   1. It is likely that nearly every physician in the nation can share a horror story of having a medication they prescribed or procedure they ordered put through the prior authorization process, and then having to plead their case to move forward—only to wind up talking with someone who does not have the knowledge to make the clinical decision being discussed.
   2. It may be that the health professional on the other end is not a physician. Even when they are physicians, these insurer-paid “peers” often come from a completely different specialty or know little to nothing about the disease or treatment in question. For example, an insurer-employed ob-gyn may be asked to approve or deny a prior authorization dealing with neurosurgery.
   3. Physicians need to be able to quickly connect with a physician who practices in the same specialty as they do. Getting to someone who understands the patient’s condition and medically appropriate treatments can truly be a matter of life and death.

4. Clear up what’s required and when

   1. Not having a full understanding of which treatments or medications that an insurer requires prior authorization for, what documents are required to support a request for prior authorization, or the specific reason for a denial can lead to real patient harm. In some cases, this lack of transparency can even contribute to patient deaths.
   2. “When you get a denial of a request, we often don’t know why. You don’t get told the reasoning behind the denial and it can take hours and hours to appeal a decision. And then sometimes you wait weeks or even months for a peer-to-peer consult,” according to AMA President Jesse M. Ehrenfeld, MD, MPH.
   3. Insurers must be more transparent with physicians and patients about their prior authorization requirements. They also must compile and publicly report data about decisions that the company makes regarding prior authorization.

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5. Ensure continuity of care

   1. Whether it’s a patient switching health plans or an insurer frequently requiring prior authorization for medications or other treatments on which a patient has been stable for years, prior authorization disrupts patient care and can result in relapses, unnecessary pain and suffering, hospitalization and more. For physicians, this type of prior authorization also creates additional administrative burdens.
   2. “Dealing with prior authorization is just a disaster both for physicians, but more so for the patient. They’re put in situations where they are not sure whether they are going to get their medication, they’re not sure whether they are going to be able to have a test,” cardiologist Jerry Kennett, MD, said in a moving video that is part of a collection of AMA member physicians’ sharing their awful experiences with prior authorization in practice.
   3. If a patient enrolls in a new health plan and their condition is stabilized on a particular treatment that the new insurer requires prior authorization or step-therapy protocols for, the health plan should allow the patient to continue on their current ongoing treatment while prior authorization approvals or step-therapy overrides are obtained.

Patients, doctors and employers can learn more about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.

The AMA has achieved significant wins on prior authorization and other critical areas for physicians. Download the progress report (PDF) for more details as the AMA continues fighting for doctors.