Practice Management Toolbox

Prior authorization – a call to action


Have you noticed that you and your staff are spending more time on prior authorization than in the past? Insurance companies are increasing the number of Current Procedural Terminology (CPT®) codes for services and procedures included in their prior authorization programs. More importantly, they are doing so without providing evidence that this approach improves patient safety or decreases unindicated medical procedures. There is also no transparency about how these prior authorization processes are developed, evaluated, or adjusted over time. Physicians and their staff are pushing back on social media, calling prior authorization programs a hassle and citing lengthy waits to speak to a physician reviewer who is often not even in their specialty.

Historically, insurers have used prior authorization to control costs, particularly those related to procedures and tests that may be inappropriately overutilized or no longer the standard of care; however, current activity suggests a much broader, indiscriminate approach. For example, insurers are requiring prior authorization for whole families of services and procedures. Anthem, the second largest insurance company in the United States, recently added the entire family of esophagogastroduodenoscopy (EGD) codes to its list of procedures requiring prior authorization in 10 states including Calif., Conn., Ind, Ohio, Ky., Mo., Nev., N.H., Va., and Wisc. A conversation earlier this year with the Anthem national prior authorization team revealed that they intend to keep adding codes for all specialties to their prior authorization program, portraying the process conducted by AIM Specialty Health® (a wholly-owned subsidiary of Anthem, Inc.), as fast, simple, and easy. However, many physicians and their office staff find the prior authorization process complex, time consuming, and frustrating.

Social media is rife with accounts from physicians who were forced to cancel planned procedures because the prior authorization process took weeks instead of days, received denials, and later found out that procedures were actually approved, or found themselves in peer-to-peer review with nonphysicians. Gastroenterologists have also reported cases of patients having flares of inflammatory bowel disease because of medication delays related to a cumbersome preauthorization process.

Because prior authorization impacts gastroenterologists’ ability to provide timely care to patients, AGA and the entire physician community have been calling for regulatory change related to prior authorization in Medicare Advantage (MA) plans to reduce physician burden and enhance patient safety and care.

Last year, AGA worked with our congressional champions Reps. Phil Roe, MD, (R-Tenn.) and Ami Bera, MD, (D-Calif.) to secure 150 signatures on a letter to the CMS Administrator requesting the agency provide guidance to MA plans to ensure that prior authorization requirements do not create barriers to care.

One in every three people with Medicare is enrolled in a Medicare Advantage (MA) plan. Under current law, MA plans may not create inappropriate barriers to care that do not already exist within the original Medicare program. A recent survey by the American Medical Association found that over 90% of physician respondents felt that the prior authorization process led to delays in care for patients that could negatively impact clinical outcomes. AGA and other physician organizations are advocating for regulatory changes related to how MA plans use prior authorization.

In addition to our regulatory efforts, the AGA is working with members of Congress on legislative solutions to require the MA plans to increase transparency, streamline the prior authorization process, and minimize the impact on Medicare beneficiaries. Reps. Susan DelBene, D-Wash., Mike Kelly, R-Penna., Ami Bera, D-Calif., and Roger Marshall, R-Kans. introduced the Improving Seniors Timely Access to Care Act of 2019, legislation that would streamline the prior authorization process in the Medicare Advantage program to relieve the administrative burdens this poses for physicians and help patients receive quicker access to the medical care they need. Although this legislation only addresses MA plans, we are hopeful that this will be the first step in requiring health plans to streamline this process and ease administrative burden. Please help us increase support for this bill by contacting your legislators and asking that they cosponsor. It will take less than 5 minutes of your time and will have a significant effect, given the opposition we face from insurers. The AGA is working on your behalf to address prior authorization hassles with private payors, but to be effective we need to hear your experiences. We know private payors continue to develop more and more restrictive prior authorization policies covering an increasing number of services and procedures without evidence that these actions provide benefit to patients. Frequently, these policies are put into action without advance warning and your reports are the first signs we have that a change has been made. Reach out to the AGA via the AGA Community or Twitter to let us know what’s happening. We will take your stories directly to the insurance companies and demand that they work with us to reduce physician burden and improve transparency.

You may also consider filing a complaint with the State Insurance Commissioner. State Insurance Commissioners are responsible for regulating the insurance industry in their state and can investigate to make sure the laws in their state are being followed and providers and patients are being treated fairly. While insurance law and regulation are established at the state level, the insurance commissioners are members of the National Association of Insurance Commissioners (NAIC), which allows them to coordinate insurance regulation among the states and territories.

If you decide to file a complaint with your State Insurance Commissioner, first familiarize yourself with your state’s complaint process. Many state insurance commissioners have a standard complaint form you can download or fill out online. Be sure to keep records of all conversations and interactions with the insurance company to document the steps you’ve taken to attempt to resolve the issue. Consider creating a log of the dates, times, and nature of your contact with the insurance company.

Once you have filed a complaint, the commissioner may send a copy to the insurance company and give them a date by which they must respond. If the commissioner believes the response is sufficient, she or he will send a copy of the insurance company’s response to you. If the commissioner feels the insurance company’s response is inadequate, staff from the commissioner’s office will work with you and the insurer to resolve the issue.

While a report of one negative experience with an insurer may not be enough to elicit action, a pattern of delays and difficulties with an insurer’s prior authorization process noted by many physicians is likely to catch an Insurance Commissioner’s attention. The NAIC cannot tell a problem is widespread if providers and patients don’t report it to the State Insurance Commissioners.

Please reach out to AGA with your stories about prior authorization problems, consider reporting insurance companies that employ systems that cause undue burden and delay to your State Insurance Commissioner and help us increase support for the Improving Seniors Timely Access to Care Act of 2019 by contacting your legislators and asking that they cosponsor using this link Together, we can pressure insurers, Congress, and Medicare to relieve physician burden and help our patients receive the timely care they need.

Dr. Garcia is a member of the AGA Practice Management and Economics Committee’s Coverage And Reimbursement Subcommittee and clinical assistant professor of medicine, gastroenterology & hepatology, Stanford Medicine, Stanford, California. Dr. Mathews is a member of the AGA Government Affairs Committee and leads efforts in clinical innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.

Tihs story was updated on July 29, 2019.

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