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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