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Prior authorization: Physician groups take aim at insurance hassles


More than 370 physician groups have come out in support of legislation they say would simplify and streamline some prior authorizations

More than 370 physician associations wrote a letter to Congress urging members to support legislation that would simplify and streamline prior authorizations for Medicare Advantage patients.

The physician groups-which include groups that represent primary care physicians such as the American College of Physicians, the American Academy of Family Physicians, the American Osteopathic Association and more-are pushing Congress to support the Improving Seniors’ Timely Access to Care Act of 2019, which has been introduced by a bipartisan group of representatives.

“This bipartisan legislation would help protect patients from unnecessary delays in care by streamlining and standardizing prior authorization under the Medicare Advantage program, providing much-needed oversight and transparency of health insurance for America’s seniors,” the letter reads. “We urge you to join your colleagues in supporting this important legislation.”

The bill has five key provisions. According to the letter, it would:

  • create an electronic prior authorization program including the electronic transmission of prior authorization requests and responses and a real-time process for items and services that are routinely approved;

  • improve transparency by requiring plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials;

  • require plans to adopt transparent prior authorization programs that are reviewed annually, adhere to evidence-based medical guidelines, and include continuity of care for individuals transitioning between coverage policies to minimize any disruption in care;

  • hold plans accountable for making timely prior authorization determinations and to provide rationales for denials; and

  • prohibit additional prior authorization for medically necessary services performed during a surgical or invasive.

Streamlining prior authorizations for Medicare Advantage patients could be a major relief to physician practices and the health system. A 2019 Kaiser Family Foundation report shows that more seniors are choosing Medicare Advantage plans, and that nearly half of all Medicare patients (47 percent) will be using Medicare Advantage by 2029.

Prior authorization is one of the issues that physicians say is ruining medicine. They say it gives payers too much power to dictate treatment plans, snarls practice efficiency with extra administrative burdens and gets in the way of the physician-patient relationship.

In surveys, physicians tell Medical Economics that prior authorization is one of the most challenging issues they deal with each year, and one of the leading causes of physician burnout.

The letter coincides with a Congressional hearing on prior authorization, in which four physicians told the House Committee on Small Business how prior authorizations get in the way of patient care.

“While there may be a limited number of justifiable cases where prior authorization is appropriate,” said John Cullen, MD, AAFP’s president, “it is clear that health plans more often require prior authorization as a cost containment strategy by limiting and restricting access to specific services.”

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