Comprehensive Prior Authorization Reforms Needed, Medicine Tells Feds
By David Doolittle


As the Centers for Medicare & Medicaid Services (CMS) seeks ways to relieve the burdens of prior authorization (PA) on health care, it should not rely solely on automation of electronic health records (EHRs). 

Instead, CMS should seek comprehensive reforms that include transparent PA requirements and protections of continuity of care as well as automation, the Texas Medical Association, American Medical Association, and a host of other medical societies wrote in a letter to CMS Administrator Seema Verma last week. 

The letter specifically addresses CMS’ heavy investment in the Da Vinci Project, a private-sector initiative that seeks to improve how clinical data is shared using patient information from physicians’ EHRs. It was founded by several health plans, care providers, and vendors, including Allscripts, the Blue Cross Blue Shield Association, Surescripts, and UnitedHealthcare. 

“While Da Vinci holds promise, there are a series of issues with exclusively relying on technology to address the burdens of PA,” the letter said. Those issues include:

  • Manual reviews will still be required, creating more care delays because of the ease and speed in which data would be exchanged;
  • Payers will have unprecedented access to EHRs;
  • Payers could coerce physicians to use technology through contract requirements; and
  • The costs and timeframes for practices to implement new technology remain unclear. 

“Of considerable concern, Da Vinci likely will not offer relief from PA for small practices in the near future,” the letter said. 

The letter urges CMS to require health plans to follow the Consensus Statement on Improving the Prior Authorization Process, issued in January 2018 by the AMA, the American Hospital Association, America’s Health Insurance Plans, and others. That statement identified “opportunities to improve the prior authorization process, with the goals of promoting safe, timely, and affordable access to evidence-based care for patients; enhancing efficiency; and reducing administrative burdens.” 

Insurance companies’ prior authorization requirements and approval processes have been a persistent thorn in physicians’ sides for years. 

“Physician practices report completing an average of 31 PAs per physician per week,” the letter to Ms. Verma said. “This workload consumes 14.9 hours (nearly 2 business days) each week of physician and staff time and reflects time that would be better spent with patients.” 

According to a recent American Medical Association survey, 86% of American physicians rated the prior authorization burden in their practices as “high” or “extremely high,” and 50% said that burden has “increased significantly” in the past five years. 

The Texas Legislature took some positive steps this year, thanks to TMA's advocacy, with the passage of Senate Bill 1742, a new law that requires state-regulated health plans to post any prior authorization requirements on the internet. The law also opens the door for utilization reviews to be conducted earlier in the appeal process by a physician in the same or similar specialty as the physician requesting treatment approval. 

However, prior authorization still puts up too many barriers between patients and physicians, state Rep. Tom Oliverson, MD (R-Cypress) told physicians at TMA’s Fall Conference last week. Prior authorization will be a top priority of his during the next legislative session in 2021, Representative Oliverson said. 

To help spur other state lawmakers to makes significant changes to prior authorization, TMA plans to collect and publicize patients’ prior authorization nightmare stories before the 2020 elections and 2021 session. 

“We want to build enough momentum that lawmakers have no choice but to pass comprehensive prior authorization reforms,” TMA President David C. Fleeger, MD, said.

Please submit your stories via TMA’s secure portal. It is important to ensure that your story submission complies with state and federal laws, including, to the extent applicable, the HIPAA privacy rule. HIPAA’s safe harbor list of 18 de-identification requirements, in accordance with Code of Federal Regulations, is available here. We won’t use or publicize your stories without reaching out to you first.

Last Updated On

November 30, 2023

Originally Published On

September 25, 2019

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