That is the focus of new reform principles developed by the American Medical Association in partnership with other medical academies to reduce the cost and inefficiencies of prior authorizations.
As AMA and other associations note, prior authorization is part of the health plan cost-control process that requires providers gain approval before performing a service to qualify for payment. The process is necessary for pharmaceuticals, durable medical equipment, and medical services to attain from health insurers in order to proceed with treatment. However, the process is not very cost- or time-efficient, and delays in treatment can yield negative repercussions for patient outcomes.
AMA anticipates integration of these principles into the current prior authorization process will allow patients timely access to treatment and reduce administrative costs to the healthcare system.
According to the organization, these principles centered on clinical value, continuity of care, transparency and fairness, timely access and administrative efficiency, and alternatives and exemptions will yield favorable results. The 21 principles aimed at working toward achieving these overarching goals in prior authorization span five categories:
Among them is one principle aimed at EHR-related improvements to e-prescribing:
As the reform principles document notes, provider EHR access to accurate formulary, prior authorization, and step therapy requirements “critical” to ensuring patients benefit from quality data at the point of care.
“When prescription claims are rejected at the pharmacy due to unmet prior authorization requirements, treatment may be delayed or completely abandoned, and additional administrative burdens are imposed on prescribing providers and pharmacies/pharmacists,” the document states.
Elsewhere in the transparency and fairness category where this EHR-related principle occurs, AMA and its partners also emphasize the necessity for utilization review entities to maintain transparency about all coverage and formulary restrictions and the necessary supplementary clinical documentation for meeting utilization management requirements. Some recommendations the organization makes to improve transparency among utilization review entities include making more data publicly available for research and analysis.
Clinical validity entails a clinically accurate foundation for up-to-date, accurate utilization management programs, patient-specific formularies that include prior authorization and step therapy requirements in electronic health record systems, and accountability for administered treatments.
As for continuity of care portion of the principles, patients should not be forced to interrupt or halt ongoing treatment due to management coverage restrictions on their health plans. Therefore, AMA advises utilization review entities to offer a minimum 60-day grace period for any step therapy or prior authorization protocols for patients already stabilized on a particular treatment at the time of enrollment in the plan.
AMA and its partners also emphasize the necessity for utilization review entities to maintain transparency about all coverage and formulary restrictions and the necessary supplementary clinical documentation for meeting utilization management requirements. Some recommendations the organizations make to improve transparency among utilization review entities include making more data publicly available for research and analysis.
To ensure timely access and administrative efficiency, AMA and others suggest utilization review entities specifically process transactions through NCPDP SCRIPT ePA transactions for pharmacy benefits and the ASC X12N 278 Health Care Service Review Request for Review and Response transactions for medical services benefits. Requiring a standard means through which to process transactions will encourage administrative efficiency. AMA also suggests utilization review entities make timely coverage determinations.
AMA and its partners also make a case for alternatives methods to prior authorizations as broadly applying the program imposes an unnecessary significant administrative burden on all health care providers, which is particularly unjustified in the case of those with high prior authorization approval rates and a history of appropriate resource utilization. The organization believes historically well-managed, well-performing providers should be exempt from adhering to prior authorization protocol to mitigate administrative burden.
In addition to these principles, the organizations behind these guiding principles are also advocating for model state legislation and testimony to federal advisory councils to reduce administrative burdens caused by prior authorization on providers.
For this reason, AMA and others have put model legislation in place that will improve the process and prevent delays in patient care.
Improving the process of prior authorization is a step toward implementing patient-centered care and encouraging positive patient health outcomes in the future.