A total of sixteen healthcare associations representing provider groups are calling on health insurers, benefit managers, utilization management firms and accreditation agencies for prior authorization reform processes that are invoked when physicians order methods, tests, devices and drugs.
The agencies involve: American Academy of Dermatology, American Academy of Family Physicians, the American Academy of Child and Adolescent Psychiatry, American College of Rheumatology, American Hospital Association, American College of Cardiology, Medical Group Management Association, American Pharmacists Association, American Society of Clinical Oncology, Arthritis Foundation, Colorado Medical Society, and AMA affiliates Medical Society of the State of New York, Minnesota Medical Association, North Carolina Medical Society, Ohio State Medical Association and Washington State Medical Association.
The associations have compiled twenty-one principles that should be followed in determining prior authorization reform decisions. Various of the provisions include the utilization of information technology—for instance, needing utilization review entities to publicly reveal in a searchable electronic format patient-specific utilization requirements like prior authorization, step therapy and formulary restrictions with patient cost-sharing information, applied to individual drugs and medical services.
Other information technology provisions cover utilization review entities providing and vendors displaying precise patient-specific and up-to-date formularies that involve prior authorization reform and step therapy requirements in electronic health records (EHRs) systems for purposes that involve e-prescribing; and publishing prior authorization approval and denial rates on their web sites or other publicly available sites.
This information should involve healthcare provider types and specialty; medication, test or procedure; indication; total annual prior authorization requests, approvals and denials; and reasons for denials and denials overturned upon appeal.
3 requirements are specifically significant to physicians, claims Robert Tennant, director of health information technology policy at the Medical Group Management Association. The first involves the public disclosure in electronic format of patient-specific requirements.
“We require a line in the sand with best practices to make better the process,” Tennant said. “A lot of it is just common sense. Prior authorization reform to run a CAT scan on an automobile accident victim shouldn’t be required.”
MGMA also is calling for consistency by health policies in setting courses of treatment. Insurers, Tennant claims, each have their own interpretations of how long a particular course of therapy should be. One payer might give twelve therapy visits for knee replacement patients, while others offer 8, 10 or 16 therapy visits. “it is all over the map,” he adds. “A physician’s judgment should be depended upon if the physician has proven to be a great partner of the payer.”
The association has extra huge concerns with 2 other principles. If a physician got approval for 4 weeks of therapy, the insurer should not come back 2 weeks later and inquire that the physician again get preauthorization, Tennant claims. And any utilization management should be deployed on up-to-date clinical criteria and never on cost alone.
The twenty-one principles of prior authorization reform are available here.
Your email address will not be published. Required fields are marked *
Aetna Announces The Completion of $1 Billion Bond Public Offering
Aetna Declares A Brighter Experience For Entire Members of Aetna Dental Team
Urgent care chain utilizes patient feedback to empower performance
Patrick Conway is quitting CMS to supervise BCBS North Carolina
Copyright© 2015 Healthcare insurance News All Right Reserved