FEATURE a standard for years . The consensus goes on to suggest that analytics be performed to ascertain the cost-benefit of prior authorization for each item on the list . In other words , is the administrative cost to the insurer and the physician greater or lesser than the cost-savings achieved by disallowing coverage of less appropriate drugs or services ? In my current health plan in Pittsburgh , we just went through that exercise and removed 260 CPT codes from our prior authorization list .
The third bullet point describes communication that is open and bilateral . There needs to be sufficient time for physician practices to adjust before a prior authorization requirement is changed . In point of fact , all states but Texas require that health plans give at least a 60-day notice to physicians in its network before a change can be made to the prior authorization list . In the Lone Star State , the requirement is 90 days .
The fourth agreed upon bullet point is one of contention but does encourage continuity of care for at least a transition of care timeframe if a patient becomes insured by a plan that does not include the patient ’ s doctor . The agreement also calls for continuity of medications if there are no acceptable alternatives .
The final bullet point calls for greater use of technology including the development of an “ industry-wide adoption of electronic prior authorization transactions based on existing national standards .” That one statement recommends that all insurers adopt the same platform in just the same way as a bank card from one financial institution will work in any bank ’ s ATM . All prior authorizations systems functioning the same way would be a boon to medical practices . Currently Availity and NaviNet do much of the same function but do so by translating the physician practice inputs into the language of each participating insurer . This bullet also calls for keeping the clinical logic in prior authorization up to date with current medical practice . How often do oncologists find that a chemotherapy or biologic that is considered a new standard of care is denied because the insurer ’ s medical policy is in need of updating ?
New developments in technology are emerging around the country that let insurers or medical review companies deploy software that can go into the physician ’ s electronic medical record to extract the information needed to satisfy the requirements of the prior authorization logic . Some of the software programs also use natural language processing ( NLP ) to pull data from free text comments . EviCore in Nashville is one such company . While this does not require the physician practice to cull the medical records for submission of prior authorization required data , it does mean that there is legal extraction of information performed without the physician ’ s direct knowledge . This is the upside , and the downside , to advanced artificial intelligence ( AI ) in performing prior authorization . activity through its Advocacy Resource Center . ( 3 .) Kentucky and Indiana have not been nearly as active as other states in putting in requirements of fairness , turnaround time and qualifications of reviewers . While not in place yet , West Virginia ’ s legislature is proposing new laws that would put more restrictions on insurance company prior authorization programs . Delaware requires all adverse decisions of a prior authorization request to be called back to the physician office by 1 p . m ., to allow the doctor time to make an appeal or make other care arrangements .
Where is all this going ? Odds are that prior authorization will be more and more limited in its use . Instead Value Based Reimbursement ( VBR ) will be the new norm . The rewards and penalties will accrue to those physicians in a VBR arrangement based upon use of resources and quality of care parameters . This is entirely different than the older capitation models which are only successful for large practices with tens of thousands of patients . In Value Based Reimbursements physician practices are competing with each other for the pool of available dollars based upon their costs of care and outcome metrics . Medicare is leading the way . By next year , they anticipate that two-thirds of reimbursement will come from their VBR arrangements . Insurers will be at half of that . But this is the future . Prior authorization is becoming more limited at the same time as Value Based Reimbursements are rising . One can only speculate regarding the impacts of direct employer contracting such as the joint venture between Berkshire-Hathaway , Amazon and JPMorgan . That group has hired as its chief executive officer Atul Gawande , the Harvard surgeon and New Yorker writer . ( 4 .) The mergers of retailers and insurers will change the role of traditional insurer . What will Aetna-CVS or Humana-Walmart look like ? How will physicians fit into these new models ? This is what we must worry about as prior authorization becomes more controlled .
References :
1 . Payer prior authorization requirements on physicians continue rapid escalation : increasing practice overhead and delaying patient care . MGMA Stat , 2017 https :// www . mgma . com / data / data-stories / payer-prior-authorization-requirements-on-physicia
2 . Consensus Statement on Improving the Prior Authorization Process . American Medical Association . https :// www . ama-assn . org / sites / default / files / media-browser / public / arc-public / prior-authorization-consensus-statement . pdf
3 . 2018 Prior Authorization State Law Chart . American Medical Association Advocacy Resource Center . https :// www . ama-assn . org / sites / default / files / media-browser / public / arc-public / pa-state-chart . pdf
4 . Amazon , Berkshire Hathaway and JPMorgan Name C . E . O . for Health Initiative . New York Times . June 20 , 2018 https :// www . nytimes . com / 2018 / 06 / 20 / health / amazon-berkshire-hathaway-jpmorgan-atul-gawande . html
Dr . James is the Senior Medical Director for Highmark Inc . in Pittsburgh , PA .
States are hearing more about problems with prior authorization from patients and physicians ( translate that to voters and donors ) and are starting to respond . The AMA is tracking much of this
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