Posted by Christina Flack on October 4, 2024
Prior authorization (PA) processes have become a significant challenge for physicians, leading to delays in necessary treatments and increased administrative burdens which negatively affect patient care. Recognizing these challenges, the Medical Association of Alabama is committed to supporting comprehensive and meaningful PA reforms, both in Alabama and Washington, D.C., which build on the success seen in other states as well as with some federally-regulated plans.
For context, 35 states have established laws regarding response times for PA requests, with 11 states mandating a 24-hour response for urgent care and 15 states requiring 48 hours. Additionally, for non-urgent care, 11 states require a 48-hour response and 10 states require responses in less than 72 hours.
Regarding patients with chronic conditions and prior approval for a medicine or treatment, Medicare Advantage plans now must maintain coverage for the entire course of treatment once one is approved. As well, 90-day grace periods for patients switching health plans or products have also begun being implemented in various states. In neighboring Tennessee for example, in 2025 carriers must begin honoring an existing PA for the first three months of an enrollee’s coverage under a new health benefit plan. Similar requirements are in place in other states as well and Medicare Advantage now requires (effective January 2024) a 90-day grace period for patients changing plans.
As hard as PAs are on patients and their physicians, once approved, they should be honored to prevent disruptions in treatment plans and additional administrative burdens. Medicare Advantage plans as of January 2024 cannot retroactively deny coverage and currently, 24 states, including Louisiana, North Carolina, and Tennessee, mostly prohibit retroactive denials once approved except in extreme instances.
Actual review of a physician’s submitted PA is another area of contention where significant progress can be made. The sooner a physician licensed in the same state in the same or similar specialty with experience treating the condition in question is involved in the PA, the better for patients. But why wait until an adverse determination is made? If a physician requests a peer-to-peer review for his or her patient’s needs, the physician should timely receive one. Utilization of non-physicians and even artificial intelligence to vet medical necessity are areas of significant concern the Association believes needs significant safeguards to protect patients against inappropriate denials of care and ensure that clinical decisions are made by qualified physicians who fully understand the complexities of patient care.
Transparency in understanding what is required by payers for PA processes is also essential. Things like the clinical criteria and other standards utilized in review, not to mention a list of the medical services and drugs requiring prior authorization, should be clearly posted on payers’ websites. Best practices and current trends dictate what new criteria or requirements regarding PAs should be announced at least 90 days before implementation in order for practice workflows to be adjusted to meet patients’ needs. Currently, 24 states require 90 days’ notice of new requirements, including Georgia, Tennessee, and Louisiana. Additionally, multiple states prohibit inquiries for unrelated medical information from being included in PA processes.
Annual public reporting of PA denials is becoming widely available, specifically related to the percentage of approvals versus denials for all codes or groups of codes requiring prior authorization. Currently, 19 states require public reporting, including Georgia, Louisiana, and Tennessee, with nine requiring posting to insurers’ websites and 10 requiring reporting to a state agency or public official. A few states go so far as to require an agency or public official to issue a report to the public or state legislature. Furthermore, Medicare Advantage, Medicare, Medicaid, Medicaid MCOs and many QHPs will soon be required to report PA metrics on their websites under the CMS interoperability/PA rule.
As PA processes progress toward all-electronic methodologies, varying standards are being implemented. The “gold standard” for drug electronic PAs – the NCPDP – has been adopted in 14 states, including Georgia and Tennessee.
Speaking of the “gold standard”, developing programs that reduce the frequency of prior authorization requirements for providers with high approval rates – known as gold-carding – would highly improve patient satisfaction, practice workflow and could help reduce health plan administration costs. Best practices and current trends indicate programs are granting “gold card” status for 12 months with semi-annual redeterminations. Currently, 21 states, including Georgia, Tennessee, and Louisiana, have implemented some type of gold-carding or similar programs, with varying eligibility requirements.
The Medical Association is committed to seeing PA reforms like the aforementioned ones implemented in both Washington, D.C., and here in Alabama. The Association is currently working collaboratively with multiple large payers in Alabama to implement these changes for patients and their physicians.
What can physicians do?
Physicians can play a crucial role in advancing our efforts by visiting the Association’s Prior Authorization Reform website at ALFixPriorAuth.com. Here, you can learn more about the campaign and share your experiences. Providing a testimonial about how prior authorizations impact your ability to practice medicine and delay patient care will significantly strengthen our advocacy. Your voice is vital in driving change.
We invite you to share your story on how prior authorizations affect your practice and delay patient care. Your testimonial will help us illustrate the administrative burdens and patient care delays caused by current prior authorization processes, reinforcing the urgent need for reform.
Please visit ALFixPriorAuth.com to submit your testimonial. Your participation is essential in our efforts to advocate for a more efficient and patient-centered healthcare system.
Evans Brown, Manager of Government Relations & Public Affairs at the Medical Association of the State of Alabama.
