Posts Tagged prior authorization

Prior Authorization Delays ‘Disheartening’ as Patients Suffer and Wait for Care, Says Alabama Doctor

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Prior Authorization Delays ‘Disheartening’ as Patients Suffer and Wait for Care, Says Alabama Doctor

Dr. Amanda Williams, President of the Medical Association of the State of Alabama, recently spoke out on Alabama Public Television’s Capitol Journal about a new campaign to reduce delays in patient care caused by prior authorizations.

Delays caused by prior authorization are a growing problem that leave frustrated patients stuck waiting for medical care their doctors say they need.

“You have a patient who has just come in and they’re excited to feel better. They’re finally getting the treatment that they need or the diagnostic test that they need and then they’re hit with more delays,” Dr. Williams said of prior authorization requirements. “From a patient’s perspective, it can be very disheartening.”

Prior authorizations were once reserved for high-cost treatments, but today, even routine care can be delayed or denied because of these insurance requirements.

According to Dr. Williams, prior authorization is more than just a nuisance; it can significantly impact a patient’s health and well-being.

“The problem is it has now morphed into requiring paperwork for very routine medications, routine imaging, routine care and it causes significant delays in treatment,” said Dr. Williams. “Usually it can take days to get a response and often it will just be a denial and require an appeal and then take even longer. So it can really slow up treatment.”

Physicians are feeling the strain of prior authorization as well, with entire teams now dedicated solely to navigating the red tape.

“We have entire staff that their whole job is doing prior authorizations,” Dr. Williams said. Prior authorizations also result in fewer patients being seen by physicians. A survey of Alabama doctors found that 76 percent said the time they spend on prior authorizations means they see fewer patients in a day. One-third of doctors said they and their staff spend nearly an entire workday each week filling out prior authorization paperwork, following up with phone calls and fighting denials.

In response, the Medical Association and a coalition of health care partners has launched a new online platform—www.ALFixPriorAuth.com—where Alabamians can share their stories of prior authorization roadblocks. The website and the initiative behind it aim to encourage faster insurance approvals for needed medical care.

Physicians are calling for important reforms, including eliminating repeat authorizations for chronic conditions and quicker responses from insurers. The stories submitted through the website will be crucial in driving these changes.

Watch Dr. Williams’s full interview on Capitol Journal here.

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Medical Association Endorses Prior Authorization Bill Reintroduced in Congress

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Medical Association Endorses Prior Authorization Bill Reintroduced in Congress

On June 12, bipartisan lawmakers introduced an updated version of the Improving Seniors’ Timely Access to Care Act in both the House (H.R. 8702) and Senate (S. 4532). The Medical Association is supporting the latest version of this legislation that was introduced, once again, by Senators Roger Marshall, MD (R-KS), Krysten Sinema (I-AZ), John Thune (R-SD), and Sherrod Brown (D-OH), as well as Representatives Mike Kelly (R-PA), Suzan DelBene (D-WA), Ami Bera, MD (D-CA) and Larry Bucshon, MD (R-IN). 

In the 117th Congress (2021-2022), the Improving Seniors’ Timely Access to Care Act garnered more than 378 total bipartisan cosponsors in the House and Senate and also passed the full House of Representatives. In addition, the legislation secured endorsements from more than 500 outside organizations, including the Medical Association of the State of Alabama and numerous other national and state medical societies.  

Unfortunately, the version of this bill that passed the House in the 117th Congress was never considered in the Senate because it produced a score of $16 billion from the Congressional Budget Office (CBO), thus necessitating modifications to lessen the bill’s fiscal imprint. While electronic prior authorization rules that the Biden administration finalized in Jan. 2024 lowered the $16 billion score substantially, the recently introduced bill is amended to ensure it ultimately scores as close to $0 as possible.  

More specifically, the legislation requires the Office of National Coordinator for Health Information Technology (ONCHIT) and the Centers for Medicare & Medicaid Services (CMS) to submit a report to Congress on the use of prior authorization in Medicare Advantage and what constitutes “real-time decisions” for “routinely approved services.” The legislation also delegates explicit authority to CMS to implement this newly defined real-time prior authorization decision-making process for routinely approved services in Medicare Advantage. Finally, the legislation delegates explicit authority to the secretary of Health and Human Services to enforce the real-time prior authorization processes for routinely approved services and issue tighter timelines for health plans to make utilization management decisions, such as 24 hours for emergent services.  

Of note, the legislation is unchanged as it relates to: 

·         Mandating compliance with uniform electronic prior authorization technical standards 

·         Barring Medicare Advantage plans from utilizing faxes or proprietary payer portals 

·         Including robust transparency requirements (e.g., disclosure of policies and evidence utilized in formulating prior authorization, listing of all services subjected to prior authorization, how many services are denied and overturned on appeal, etc.) 

·         Permitting insurers to create gold-carding programs 

Click here for the Endorsement List.

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Here’s How Alabamians Can Fight Insurance Red Tape That Delays Medical Care

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Here’s How Alabamians Can Fight Insurance Red Tape That Delays Medical Care

Alabama doctors and patients frustrated with delays in care caused by insurance companies’ prior authorization process now have a new way to share their stories and promote change.

A new online platform — www.ALFixPriorAuth.com — invites Alabamians to share their experiences with prior authorization problems. The website and the initiative behind it to encourage faster insurance approvals for medical care was started by doctors with the Medical Association of the State of Alabama.

Doctors say delays caused by prior authorizations can have dangerous impacts on their patients’ health.

>>>Watch this video: Doctors Discuss the Burdens of Prior Authorization<<<

“With prior authorizations, we definitely see a delay in patient care,” said Dr. Tonya Bradley, a physician in Auburn. “I see delays in patients getting chemo, I see delays in patients getting tests they need to diagnose problems that can be very urgent.”

What is Prior Authorization?
Before your doctor provides a treatment, your insurance requires them to prove you need it. Decades ago, prior authorization was used sparingly and typically only to make sure some expensive treatments were absolutely necessary.

But today, even routine medical care requires insurance approval. Denials mean patients and doctors must spend time fighting insurance companies for care.

Takes Time Away From ‘What Really Matters’
When doctors have to spend time arguing with insurance companies over prior authorizations, it means there’s less time for doctors to spend with their patients – their number one priority.

“The bureaucracy. The paperwork. The institutional inertia. The list goes on and on, and it makes it very difficult for us to do what really matters, which is take great care of our patients,” said Dr. George Koulianos of Mobile.

What Alabamians Think
A survey of Alabama doctors found that 76 percent said the time they spend on prior authorizations means they see fewer patients in a day. One-third of doctors said they and their staff spend nearly an entire workday each week filling out prior authorization paperwork, following up with phone calls and fighting denials.

A separate survey of 500 Alabamians showed that 80 percent agree with the statement that “doctors in Alabama are working to spend more time with patients, so that patients and doctors have the time together to make the best health care decisions.”

Dr. Hernando Carter said being able to spend more time with patients rather than prior authorizations results in better health care.

“If you can spend the time to explain to your patient why you’re recommending a test or why you’re recommending a treatment and be able to answer all the questions they have and assuage any concerns or apprehensions they have, then that directly affects how well they do. It directly affects whether they get better or not,” the Birmingham physician said. “So, we abhor anything that interferes or cuts into that time that we have to do that with our patients.”

“We need to have the ability to take care of our patients in an efficient manner, expedite the care and not go through all the red tape,” said Dr. William Admire of Mobile. “When we slow down the progress of patients’ recovery, no one wins.”

Steps to Fix Prior Authorization
Physicians with the Medical Association have begun conversations with the health insurance community to push for changes. Stories submitted through www.ALFixPriorAuth.com will help support efforts to fix prior authorization in Alabama.

Among the changes doctors want to see are an end to repeat prior authorizations for patients with chronic conditions and faster response times from insurers.

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SURVEY: Prior Authorization Obstacles Unnecessarily Delay Patient Access to Cancer Treatments

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SURVEY: Prior Authorization Obstacles Unnecessarily Delay Patient Access to Cancer Treatments

ARLINGTON, Va., April 25, 2019 — Restrictive prior authorization practices cause unnecessary delays and interference in care decisions for cancer patients, according to a new survey of nearly 700 radiation oncologists — physicians who treat cancer patients using radiation– released today by the American Society for Radiation Oncology (ASTRO).

Nearly all radiation oncologists (93%) said that their patients are delayed from life-saving treatments, and a third (31%) said the average delay lasts longer than five days – a full week of standard radiation treatments. These delays cause added stress and anxiety to patients already concerned about their health, and they are cause for alarm given research linking each week of delay in starting cancer therapy with a 1.2% to 3.2% increased risk of death.

In addition to prevalent treatment delays, the ASTRO physician survey illuminates other ways prior authorization negatively impacts patient outcomes and takes physicians away from caring for their patients:

Added Patient Stress

  • More than 7 in 10 radiation oncologists (73%) said their patients regularly express concern to them about the delay caused by prior authorization.
  • More than 3 in 10 radiation oncologists (32%) have been forced to use a different therapy for a substantial number of their patients (>10%) due to prior authorizations delays.

Unnecessary Delay Tactics

  • Nearly two-thirds of radiation oncologists (62%) said most denials they receive from prior authorization review are overturned on appeal.
  • Radiation oncology benefit management companies (ROBMs) required 85% of radiation oncologists to generate multiple treatment plans, which require physicians and medical physicists to spend several hours developing alternatives to their recommended course of treatment.
  • More than 4 in 10 respondents (44%) said their peer-reviews typically are not conducted by a licensed radiation oncologist.

Wasting Physician Time

  • Nearly one in five radiation oncologists (17%) said they lose more than 10% of time that they could be caring for their patients focused instead on dealing with prior authorization issues. An additional 39% spend 5-10% of their average workday on prior authorization.
  • More than 4 in 10 radiation oncologists (44%) needed prior authorization for at least half of their treatment recommendations. An additional third (37%) needed it for at least a quarter of their cases.
  • Many radiation oncologists (63%) had to hire additional staff in the last year to manage the prior authorization process.

Disproportionate Impact on Patients at Community-Based Clinics

  • Patients treated at community-based, private practices experience longer delays than those seen at academic centers. For example, average treatment delays lasting longer than a week were reported by 34% of private practitioners vs. 28% of academic physicians (p=0.005).
  • Radiation oncologists in private practice are almost twice as likely to spend more than 10% of their day focused on prior authorization, compared to physicians at academic centers (23% vs. 13%, p=0.003)

“This survey makes clear that restrictive prior authorization practices can cause unnecessary, stressful and potentially life-threatening delays for cancer patients,” said Paul Harari, MD, FASTRO, Chair of the ASTRO Board of Directors and professor and Chairman of human oncology at the University of Wisconsin-Madison. “While the system may have been designed as a path to streamline and strengthen health care, it is in fact frequently harmful to patients receiving radiation therapy. In its current form, prior authorization causes immense anxiety and wastes precious time for cancer patients.”

“Radiation oncology and cancer patients have been particularly hard hit by prior authorization’s unnecessary burden and interference in care decisions,” said Vivek Kavadi, MD, Vice Chair of ASTRO’s Payer Relations Subcommittee and a radiation oncologist at Texas Oncology. “Radiation oncologists increasingly are restricted from exercising our clinical judgment in what is in the best interest of the patient, yet we are held accountable for the outcomes of treatments where decisions have been taken out of our hands.”

In the 2018 annual ASTRO member survey, radiation oncologists named prior authorization as the greatest challenge facing the field. The burden was especially prominent among private practitioners in community-based settings, where the majority of cancer patients receive care.

The findings from ASTRO’s new physician survey align with recent reports from the American Medical Association (AMA), American Cancer Society Cancer Action Network (ACS CAN) and others, demonstrating the pervasiveness of prior authorization obstacles throughout the American health care system.

ASTRO recently signed onto a letter with the AMA and other medical societies calling for CMS to require Medicare Advantage plans to align their prior authorization requirements with a Consensus Statement on Improving the Prior Authorization Process authored jointly by leading provider and payer organizations.

Survey Methodology

An online survey was sent by email to all 3,882 U.S. based, practicing radiation oncologists in ASTRO’s member database, and 620 physicians completed the survey online. Invitations were sent in December 2018, with one email reminder in January 2019, and the survey closed in February 2019. ASTRO staff also administered paper surveys at the ASTRO Annual Meeting in October 2018 and collected 53 responses. Findings reflect the combined total of 673 radiation oncologist responses. For more information about respondent demographics, view the executive summary.

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ABOUT ASTRO

The American Society for Radiation Oncology (ASTRO) is the world’s largest radiation oncology society, with more than 10,000 members who are physicians, nurses, biologists, physicists, radiation therapists, dosimetrists and other health care professionals who specialize in treating patients with radiation therapies. The Society is dedicated to improving patient care through professional education and training, support for clinical practice and health policy standards, advancement of science and research, and advocacy. ASTRO publishes three medical journals,International Journal of Radiation Oncology • Biology • Physics, Practical Radiation Oncology andAdvances in Radiation Oncology; developed and maintains an extensive patient website, RT Answers; and created the nonprofit foundation Radiation Oncology Institute. To learn more about ASTRO, visit our website, sign up to receive our news and follow us on our blog, Facebook, Twitterand LinkedIn.

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Medical Association Signs on to Letter Targeting PA Requirements

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Medical Association Signs on to Letter Targeting PA Requirements

The Medical Association recently joined the American Medical Association and 85 other national medical groups and state medical associations in sending a letter to the Centers for Medicare & Medicaid  Services to urge CMS to provide guidance to Medicare Advantage plans on prior authorization processes through its 2020 Call Letter. In the jointly signed letter, the groups call upon CMS to require MA plans to selectively apply PA requirements and provide examples of criteria to be used for programs such as ordering/prescribing patterns that align with evidence-based guidelines and historically high PA approval rates. Citing the CMS Patients Over Paperwork initiative, the letter stresses this new guidance will promote safe, timely and affordable access to care for patients; enhance efficiency; and reduce administrative burden on physician practices.

The letter further explains how the prior authorization process has been found to be burdensome for health care providers, health plans and even patients and that physicians and insurers have agreed that these policy changes to eliminate PAs on those services for which there is low variation in care can promote greater transparency regarding services subject to PAs and protect patients to ensure PAs do not impact the continuity of care.

PA programs can create significant treatment barriers by delaying the start or continuation of necessary treatment, which may in turn adversely affect patient health outcomes. According to a 2018 AMA survey of 1,000 practicing physicians, 91 percent of physicians said PAs can delay a patient’s access to necessary care. These delays may have serious implications for patients and their health, as 75 percent of physicians reported that PA can lead to treatment abandonment, and 91 percent indicated that PA can have a negative impact on patient clinical outcomes. Most alarmingly, 28 percent of physicians indicated that PA has led to a serious adverse event (e.g., death, hospitalization, disability/permanent bodily damage) for a patient in their care.

Read the letter in its entirety

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