Prior authorization is a cost saving move used by insurances to review medical necessity. Procedures, treatment, and prescriptions are often denied based on statistical analysis rather than on the opinion of a medical professional – at times to the detriment of the patient – in fact 92% of treatment delays are attributed to prior authorization. Treatments like chemotherapy for instance.

In January, several payer and provider organizations signed a pledge designed to improve the prior authorization process. The American Hospital Association, America’s Health Insurance Plans, the American Medical Association, the American Pharmacists Association, the BlueCross BlueShield Association, and the Medical Group Management Association all signed the pledge.

The group identified five opportunities for improvement in prior authorization programs and processes with the goal of achieving “meaningful reform.” In brief, they are:

1. Selective application of prior authorization.

The organizations agreed to encourage selective implementation of prior authorization based on adherence to evidence-based medicine and to encourage adjustments to prior authorization requirements when health care providers participate in risk-based payment contracts.

2. Prior authorization program review and volume adjustment.

The organizations agreed to encourage review of medical services and prescription drugs requiring prior authorization on at least an annual basis, encourage revision of the requirements based on data and up-to-date clinical criteria, encourage sharing changes to the lists via websites and annual communication to contracted providers.

3. Transparency and communication regarding prior authorization.

The organizations agreed to improve communication channels between health plans, providers, and patient, encourage transparency of prior authorization requirements, and encourage improvement in communications channels. The latter is aimed at helping providers submit complete, timely requests and streamlining the process such that providers receive timely determinations from health plans.

4. Continuity of patient care.

The organizations agreed to encourage protections for continuity of care during patient transition periods, support continuity of care for patients by minimizing repetitive prior authorization requirements, improve communication to minimize treatment disruptions.

5. Automation to improve transparency and efficiency.

The organizations agreed to encourage the acceleration of existing national standard transactions for electronic preauthorization, advocate for the adoption of national standards for the electronic exchange of clinical documents, encourage the communication of up-to-date prior authorization to EHRs and pharmacy systems to promote the accessibility of this information to providers.

“This collaboration among health care professionals and health plans represents a good initial step toward reducing prior authorization burdens for all industry stakeholders and ensuring patients have timely access to optimal care and treatment,” said Dr. Jack Resneck, Jr., AMA chair-elect.

Dr. Richard Bankowitz, M.D., chief medical officer of AHIP, echoed that sentiment, saying: “Working together, we can find the right solutions to improve the process, promote quality and affordable health care, and reduce unnecessary burden.”