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Healthcare Groups Call for Improvements to Prior Authorization Process

January 18, 2018
by Heather Landi
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A collaborative of healthcare organizations, including the American Medical Association, the American Hospital Association, and the Medical Group Management Association, released a joint statement this week calling for improved prior authorization procedures, including automating the process to improve transparency and efficiency.

Along with the above organizations, the collaborative includes America’s Health Insurance Plans, Blue Cross Blue Shield Association and American Pharmacists Association. The groups contend that prior authorization is one of the most burdensome administrative requirements faced by medical group practices and the joint statement is an effort to solve some of the most pressing concerns associated with prior authorization.

As earlier MGMA research has shown, the number of health plan authorizations have been increasing, despite the fact that the overwhelming percentage of requests are ultimately approved. “Meeting health plan proprietary authorization requirements consume significant time for both clinical and administrative personnel, diverting staff away from providing direct patient care, and costing practices countless dollars to administer,” Anders Gilberg, MGMA senior vice president, government affairs, said in a statement. “Most importantly, the prior authorization process can result in delayed or denied patient care.”

“We have partnered to identify 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. The prior authorization process can be burdensome for all involved—health care providers, health plans, and patients. Yet, there is wide variation in medical practice and adherence to evidence-based treatment. Communication and collaboration can improve stakeholder understanding of the functions and challenges associated with prior authorization and lead to opportunities to improve the process, promote quality and affordable health care, and reduce unnecessary burdens,” the joint statement read.

The joint statement focuses on five areas: Selective Application of Prior Authorization; Prior Authorization Program Review and Volume Adjustment; Transparency and Communication Regarding Prior Authorization; Continuity of Patient Care; and Automation to Improve Transparency and Efficiency.

The group is calling for industry-wide adoption of electronic prior authorization transactions based on existing national standards, which has the potential to streamline and improve the process for all stakeholders. What’s more, the group said making prior authorization requirements and other formulary information electronically accessible to health care providers at the point-of-care in electronic health records (EHRs) and pharmacy systems would improve process efficiencies and reduce time to treatment. And, making prior authorization and formulary information accessible through EHRs and pharmacy systems would potentially result in fewer prior authorization requests because healthcare providers would have the coverage information they need when making treatment decisions, the group stated.

The group is advocating for adoption of national standards for the electronic exchange of clinical documents, i.e. electronic attachment standards) to reduce administrative burdens. And the group is calling for healthcare providers and EHR and practice management system vendors to develop and deploy software and processes that help automate prior authorization using standard transactions.


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