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ACP Joins Others in Advising CMS on Best Ways to Reduce Prior Authorization Burdens

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Medical groups call for comprehensive approach that provides improved transparency and does not focus solely on automation

Oct. 18, 2019 (ACP) – The American College of Physicians and more than 100 other medical organizations are joining forces to support and guide the Centers for Medicare & Medicaid Services' (CMS) efforts to alleviate the burdensome prior authorization process.

Medical practices report completing an average of 31 prior authorizations per doctor per week, which takes up 14.9 hours of doctor and/or staff time that could be spent with patients. In addition, delays from this process have led to hospitalization and even death among patients who are waiting on approvals for medication, tests or supplies, the groups noted in a joint letter to CMS Administrator Seema Verma.

Expressing concern that current CMS efforts to make the prior authorization process less burdensome are solely focused on automation, ACP and other organizations including the American Medical Association called for a more comprehensive approach that includes greater transparency.

CMS is invested in the Da Vinci Project, a private sector initiative that aims to harness technology to automate the prior authorization process across electronic health record (EHR) systems.

But such automation and the interoperability it promises will not fully alleviate the burdens associated with prior authorization, the group stressed. Manual review will still be necessary, which means that delays may still exist. Document exchange will be easier and faster with automation, which could lead to even more prior authorizations. Moreover, payers will have access to EHR data, and, without safeguards, these data could be used as a determining factor for coverage. ACP spelled out many of these concerns and suggestions in an earlier letter to Verma in August 2019.

“Prior authorizations are burdensome because they happen outside of the workflow or after the patient encounter, the requirements aren't clear and differ across payers and plans, and the data is not updated regularly,” said Brooke Rockwern, an ACP associate for health IT policy. Rockwern joined ACP President Dr. Robert McLean and other ACP staff at a meeting with CMS administrators this summer to discuss reducing these burdens.

Automation is important, but it is just one part of a multipronged solution, Rockwern said. Transparency is also key. “Payers must be more transparent about their prior authorization requirements to eliminate guess work on the part of physicians and their staff, and they should use standard clinical definitions for data elements,” she said.

The group also called for the removal of prior authorization requirements for services and drugs that focus on utilization or cost management, not clinical validity. Another way to streamline this process is to offer exemptions for clinicians who have a clear record of previous prior authorization approvals. “Examples would be offering a ‘gold card’ status to those physicians so they can bypass the prior authorization process,” Rockwern said.

ACP members should submit their experiences with prior authorization through the ACP data collection tool, which is part of the Patients Before Paperwork initiative. This information will provide ACP with more stories to share with legislators and help guide policy suggestions. ACP is also in the process of developing state-level advocacy resources to help reduce burdens associated with prior authorizations.

More Information

ACP's collection tool “Administrative Tasks and Best Practices Survey” is available on the ACP website.

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Back to the October 18, 2019 issue of ACP Advocate