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AMA Adopts New Prior Authorization Reform Policies
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Medical leaders and medical students at the Annual Meeting of the American Medical Association The House of Delegates approved policies aimed at fighting for greater accountability and transparency from insurers regarding prior authorization requirements – issues that the AMA says are denying patients needed care and adding administrative burdens to doctors.
Policies adopted by the House of Delegates address what it considers to be the need for greater oversight of health insurers’ use of prior authorization controls on patients’ access to care.
WHAT IS THE IMPACT?
According to the AMA, health plans continue to improperly impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices. These policies, in the group’s opinion, compromise the quality of care, leading the agency to advocate greater legal accountability for health insurers when prior authorization is considered to be harming patients.
Doctor surveys generally found that excessive authorization controls required by health insurers lead to harm when necessary medical care is delayed, denied, or interrupted. Investigations of inspector general’s office of Department of Health and Human Services It is Kaiser Family Foundation in prior authorization of Medicare Advantage plans suggest that insurers are denying medically necessary health care.
The AMA said it would also work to ensure that insurers’ increased legal liability is not impeded by clauses in beneficiary contracts that may require pre-dispute arbitration for prior authorization determinations or place limitations on class action.
Citing health insurers’ prior authorization programs that include extensive denial processes, the AMA said it would work to ensure that insurers provide prior authorization notices with detailed explanations of the rationale for denying access to care.
The AMA’s new policy outlines basic information requirements for prior authorization denial letters that include a detailed explanation of the reasoning for denial, access to policies or rules cited as part of the denial, information needed to approve treatment, and a list of alternative treatments covered.
The organization said it would also continue its work to support real-time prescription benefits tools (RTBTs) that allow doctors to access information about patients’ drug coverage at the point of care in their electronic health records. RTBTs, according to the AMA, can expedite access to care and avoid unexpected delays and denials by confirming insurer-approved care or providing therapeutically equivalent alternative treatments that do not require prior authorization from the insurer.
THE BIGGEST TREND
A final rule issued by the Centers for Medicare and Medicaid Services in January found that affected payers will be required to submit prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests.
Affects Medicare Advantage, state Medicaid, and Children’s health insurance program, fee for service programs, Medicaid managed care plans, CHIPS managed care entities and health plan issuers qualify on the federally facilitated exchanges.
Everyone is required to implement and maintain certain Health Level 7 Fast Healthcare Interoperability Resources application programming interfaces to improve the electronic exchange of health data as well as to streamline prior authorization processes.
Affected payers must also implement certain operational provisions beginning January 1, 2026.
In July of last year, the AMA, American Hospital Association and Blue Cross Blue Shield Association sent a joint letter to CMS requesting that the government agency reconsider regulatory proposals that require different electronic standards for data exchange during the prior authorization process.
The groups said that while they appreciate the administration’s efforts to reduce administrative burdens and costs in the health care system, including prior authorization reform, they described the regulatory proposals as “conflicting.” They say they potentially set the stage for multiple electronic prior authorization standards and workflows – which would contribute to the “costly burdens that administrative simplification seeks to alleviate.”
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Publication in the media.