TDI Releases Standardized Prior Authorization Forms for Medical Care, Drugs

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Economics Feature — March 2015 

Tex Med. 2015;111(3):29-34.

By Amy Lynn Sorrel
Associate Editor

A sheet or two of paper may not seem that valuable. But for Austin Internal Medicine Clinic, it means more precious time dedicated to patient care. 

New standardized prior authorization forms released by the Texas Department of Insurance (TDI) promise to wipe away some of the administrative busy work and related costs that take physicians like Gilbert Blancarte, MD, away from that priority.  

"Prior authorizations are really a big hassle, and it would be better if we didn't have to do them," he laughed. "But since we do, having a universal form would be wonderful. It helps us get approved more quickly and getting an answer one way or another so we can either give the patient what they need or look for an alternative." 

Even for the same medication, from one patient to the next, it's not unusual for his office administrator to fill out four or five different prescription authorization forms — sometimes four or five pages each — for the many commercial insurance plans the practice accepts. That's after researching patients' individual health plans and formularies and whether preauthorization is needed in the first place. And that doesn't include the handful of additional forms she may fill out for services like home health care. 

Some practices dedicate one employee to do nothing but prior authorizations. As a solo physician practice, however, Austin Internal Medicine Clinic cannot afford that luxury. 

"I'm it," said Sharon Blancarte, Dr. Blancarte's wife and office administrator. 

Nor is it unusual for patients to experience delays in getting their prescriptions because she has to go back and forth with both the insurance company and its pharmacy benefit manager — and Dr. Blancarte — to fill out separate forms for each entity. 

For the most part, insurers ask for similar information. 

"But it's like going to check out for groceries, and every single credit card machine is different, and they ask you different questions in different order," Ms. Blancarte says. "It takes me time to do it. You have to have just the right information. And if I have patients waiting, I can't be stuck on the phone. It would be so much easier on us if everyone asked the same thing. And it means patients get their prescriptions sooner rather than having to wait." 

Making Life Easier

Thanks to two of the Texas Medical Association's 2013 legislative victories, the day has arrived when physicians no longer have to deal with hundreds of different prior authorization forms from multiple payers.

Beginning Sept. 1, physicians can use a single, uniform, paper prior authorization form for prescription drug benefits and a similar standardized form for medical and health care services. TDI and health plans must make the forms available in paper form and electronically on their websites. 

At press time in January, TDI posted a copy of the medical services prior authorization form, which can found at tma.tips/priorauth. (Also see "For Your Staff.") Public comment regarding the prescription drug prior authorization form was still under way, and the department expected to release it by March. 

TMA physician leaders and lobby staff worked hard to pass Senate bills 644 and 1216 in 2013. They required TDI to appoint workgroups that included physicians, hospitals, pharmacies, health plans, and others to design the forms for use across public and private payers in Texas, including:  

  • Commercial carriers, 
  • HMOs, 
  • Medicaid and Medicaid managed care organizations, 
  • The Children's Health Insurance Program (CHIP), and 
  • Plans covering employees of the state of Texas, most school districts, and The University of Texas and Texas A&M University systems.  

Medicare, the state Workers' Compensation program, and self-funded employer plans are excluded. 

TMA research shows that a single health plan could have dozens of precertification forms for various procedures and drugs, and these and other administrative interactions with insurers cost an average of $80,000 per physician per year.  

The laws do not require physicians to use the standardized forms, but for those choosing to do so, health plans must accept them as valid prior authorization requests. 

Bruce Levy, MD, is chief executive officer of Austin Gastroenterology PA and a former executive director for the Texas Medical Board who serves on the workgroup that developed the medical and health care services prior authorization form. 

"Our No. 1 goal was to create a single-page form that could be used interchangeably for every third-party payer," he said. "Just like we have a common credentialing form, this is the first step in creating a common form for preauthorization. And we believe what we came up with is not overly onerous for physicians, but also provides a great deal of information to help third-party payers make their decisions." 

The medical and health care services form, for example, contains six standardized fields asking physicians for information on:  

  • The patient's health plan,
  • Whether the request is urgent,
  • The patient, 
  • The physician or facility making the request,
  • The services requested and related codes and diagnoses, and
  • Clinical documentation. 

In fact, health plans may already prepopulate their contact information on the forms posted on their websites. 

Because the prescription medication form covers compound drugs and some devices, that document is two pages, says Gary J. Sheppard, MD, an internist at Southwest Memorial Physician Associates in Houston, who serves on that workgroup. 

"But the most important thing is, it's going to be the same, whether it's Aetna, Blue Cross, Humana, or Medicaid," he said. "The fact that we have to use only one form and can get it done and move on to more important things makes our lives a lot easier."

As part of the Texas Health and Human Services Commission's own administrative simplification overhaul, which includes streamlining Medicaid prior authorization, officials told Texas Medicine the agency coordinated with TDI to avoid any duplication of work. (See "Seeking Simplicity," August 2014 Texas Medicine, pages 33-37.) 

Collaborative Effort

During the 2013 legislative debates, while generally on board with the idea of standardization, health insurers initially bristled at the possibility of condensed forms over concerns that too little information could cause care delays if plans couldn't ask additional questions at the outset. A complicated hip replacement, for example, may require more information than a mole removal. 

But Dr. Levy says, "Once the uneasiness was overcome, there was a great collaborative effort by everybody to try to create a form that would work," adding that health plans indicated it could help reduce some of their work burden, as well.

Dr. Sheppard agrees the biggest challenge was "figuring out how much to put on the form. Health plans always want more information, but it's not always readily available to us [physicians]." 

For example, insurers may ask for patients' five-year prescription history, but they've only been under Dr. Sheppard's care or with their current insurance plan for two years. Plans also typically ask for National Drug Code numbers for active and inactive ingredients in compound medications.

"But we [doctors] don't always know. It might be available in some EMRs (electronic medical records). But not all physicians have that information and would have to look it up. And pharmacists chimed in to say, 'We know that in the pharmacy. But that's not something doctors are going to know,'" Dr. Sheppard said. The discussions were productive, he adds, "and really brought some reality to what [insurers] think they want and what can actually happen." 

Health plan representatives did not respond to Texas Medicine's requests for comment. 

TDI Special Advisor for Policy Development Patricia Brewer clarified that the legislation and the new forms do not change insurers' approval criteria or processes required to support the medical necessity of a particular procedure, for example. Nor can physicians use the standardized forms to:  

  • Request an appeal, 
  • Confirm eligibility,
  • Verify coverage,
  • Ask whether a service requires prior authorization, or
  • Request an out-of-network referral.  

Rather, Ms. Brewer says, the efforts bring at least some standardization to what's already required of practices during the preauthorization process. 

The agency coalesced and considered existing prior authorization forms used by plans, including Medicaid, as well as national standards, and looked at other state models for uniform precertification forms. The final products, she says, give practices a simple way to initiate the preauthorization process; identify the patient and procedure or drug requested; and if needed, attach any additional medical documentation insurers might require as part of their approval criteria.

Next:  Electronic Version

Drs. Levy and Sheppard also emphasized that the project was just the beginning of what they anticipate will be ongoing discussions to create a standard form that eventually practices can file electronically. 

"That's where the real savings are for practices because then a lot of this can be done without using the phone and waiting," Dr. Levy said. "The legislature only required a written form, and that's what we did. But this will be the basis for what we can do electronically to allow all practices to obtain this information easily and quickly."

In formatting the prescription drug form, for example, Dr. Sheppard adds the workgroup had help from health plan representatives with experience drafting electronic versions in other states to create fields that Texas practices could easily populate with an EMR system in the future.

Once national, HIPPA-compliant electronic standards for prior authorization are adopted, the laws give TDI and health plans two years to make available and accept electronic versions of the state's standardized forms. 

TMA officials note that some health plans already offer an electronic option, and nothing in SB 1216 or SB 644 prohibits plans or practices from going that route. Practices also may continue using insurers' existing preauthorization forms if they are more familiar. However, if practices prefer the new standardized forms, the laws require health plans to accept them.

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

SIDEBAR

For Your Staff

Beginning Sept. 1, physicians can use a single, uniform, paper prior authorization form for medical and health care services and a similar standardized form for prescription drug benefits. Texas Department of Insurance (TDI) officials say health plans may start accepting the forms before then. 

The agency posted a copy of the medical and health care services form and its instruction sheet, which can be found at tma.tips/priorauth. You may also request the documents by mail from Texas Department of Insurance, Rate and Form Review Office, Mail Code 106-1E, PO Box 149104, Austin, TX 78714-9104.

TDI expects to release the prescription drug form by March. The forms must be reproduced without changes.

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