Physicians, pharmacists, medical groups, hospitals, and health insurance providers are working together to improve prior authorization processes for patients' medical treatments, also known as pre-approval. This will help patients have access to safe, timely, and affordable care, while reducing administrative burdens for both health care professionals, hospitals and health insurance providers.
If a treatment or prescription requires prior authorization, it must be approved by a health insurance provider beforehand. This is one way health insurance providers help ensure a treatment is safe and supported by scientific evidence. When applied appropriately, these processes help to maximize the value of every dollar spent on coverage and care.
Prior authorization approvals can be burdensome for health care professionals, hospitals, health insurance providers, and patients because the processes vary and can be repetitive. Streamlining approval processes will enhance patient access to timely, appropriate care and minimize potential disruptions. Enhanced transparency and communication also play critical roles in improving prior authorization processes, which underscores the importance of this new effort.
As the first step in this collaboration, the American Hospital Association (AHA), America's Health Insurance Plans (AHIP), American Medical Association (AMA), American Pharmacists Association (APhA), Blue Cross Blue Shield Association (BCBSA) and Medical Group Management Association (MGMA) have announced a Consensus Statement outlining their shared commitment to industry-wide improvements to prior authorization processes and patient-centered care.
According to the Consensus Statement, these health care leaders will work together to:
- Reduce the number of health care professionals subject to prior authorization requirements based on their performance, adherence to evidence-based medical practices, or participation in a value-based agreement with the health insurance provider.
- Regularly review the services and medications that require prior authorization and eliminate requirements for therapies that no longer warrant them.
- Improve channels of communications between health insurance providers, health care professionals, and patients to minimize care delays and ensure clarity on prior authorization requirements, rationale, and changes.
- Protect continuity of care for patients who are on an ongoing, active treatment or a stable treatment regimen when there are changes in coverage, health insurance providers or prior authorization requirements.
- Accelerate industry adoption of national electronic standards for prior authorization and improve transparency of formulary information and coverage restrictions at the point-of-care.
This group of health care leaders is committed to ongoing collaboration to improve the prior authorization process for health care professionals, health insurance providers, and, most importantly, patients. As experience is gained, these processes will be further refined to maximize efficiency and minimize care disruption for patients.