The prior authorization burdens associated with the process have long been a source of frustration for healthcare providers and patients. These burdens can impede optimal care by creating delays in treatment and increasing administrative tasks. However, recent legislative changes and insurer policies aim to alleviate these concerns and streamline the prior authorization process.
A radiation oncologist at The University of Texas Cancer Center, highlighted the process’s intrusive nature, stating, it places a stranger between a patient and their doctor, causing unnecessary stress and delays.
To address these issues, ten states have enacted laws this year to streamline prior authorization. At the federal level, the Centers for Medicare & Medicaid Services (CMS) have finalized rules to simplify the process and require reviews of Medicare Advantage plans’ prior authorization policies. Additionally, the HHS Office of the Inspector General is investigating Medicare Advantage organizations’ practices for handling certain prior authorization requests.
Two major health insurers have begun waiving prior authorization burdens for specific treatments and services. While initial impacts on physician practices have been limited, health insurance companies’ upcoming plans to link prior authorization exemptions to clinical practice guidelines could significantly improve the process.
Insurers Streamline Prior Authorization for Cancer Treatments
Healthcare insurance companies have taken steps to reduce the burden of prior authorization for certain cancer treatments. In 2023, Healthcare insurance company eliminated requirements for nearly 20% of its prior authorization volume, focusing on services that consistently adhere to evidence-based guidelines. This move has benefited cancer patients, particularly those requiring genetic testing or imaging.
Healthcare insurance company is further reducing prior authorization requirements through its upcoming Gold Card program. Practices that consistently demonstrate adherence to evidence-based guidelines will be eligible for reduced requirements, including exemptions for certain cancer-specific imaging.
Healthcare has also eliminated prior authorization for a significant number of medical services, including oncology drugs. The company partners with healthcare to review treatment plans and ensure they align with FDA approvals and NCCN guidelines.
These efforts by insurers represent a positive trend toward streamlining the prior authorization process and improving access to cancer care.
Experts Question the Impact of Insurer Prior Authorization Reforms
While healthcare insurance companies have implemented changes to streamline prior authorization, experts remain skeptical about their effectiveness in improving patient care. Nicolas Ferreyros, managing director of the community oncology practices, suggests that these reforms may be motivated by public relations concerns rather than a genuine commitment to patient well-being.
A survey by the American Medical Association found that prior authorization continues to be a significant burden for physicians, particularly with health insurance companies. Many providers reported high or extremely high levels of burden associated with these insurers.
Emphasized the administrative challenges faced by oncologists due to complex prior authorization forms. A professor at research institution suggested that simplifying forms and improving electronic submission systems could alleviate these burdens.
Overall, while the recent changes by insurers represent a step in the right direction, experts believe that more substantial reforms are needed to truly address the prior authorization issue and improve patient outcomes.
States and Federal Government Take Action to Address Prior Authorization
In response to concerns about the prior authorization burdens on healthcare providers and patients, states and the federal government have implemented various reforms aimed at streamlining the process and improving patient access to care
Ten states have passed legislation to reduce prior authorization requirements, decrease delays in care, and increase transparency. For example, Minnesota’s legislation prohibits prior authorization for antineoplastic cancer treatment that aligns with NCCN guidelines.
At the federal level, the CMS has finalized a rule that will require affected insurers to provide prior authorization decisions within specific timeframes and include reasons for denials. The rule also mandates the use of automated processes and public reporting of prior authorization data.
The HHS has also taken steps to address prior authorization issues. A rule finalized in April requires Medicare Advantage plans to include a health equity expert on their utilization management committees and conduct annual health equity analyses. Additionally, the HHS OIG announced an investigation into Medicare Advantage organizations’ practices for reviewing prior authorization requests for post-acute care.
Legislation introduced in Congress, such as the Improving Seniors’ Timely Access to Care Act and the GOLD CARD Act, aims to further streamline prior authorization processes and reduce burdens on healthcare providers.
These combined efforts represent a significant step forward in addressing the challenges associated with prior authorization and improving patient outcomes.
Prior Authorization: A Key to Efficient RCM for Healthcare Providers
The prior authorization process is a critical component of the Revenue Cycle Management (RCM) workflow, particularly for RCM companies managing healthcare providers’ billing operations. Prior authorization burdens can significantly impact the efficiency of the RCM process. Prior authorization (PA) involves obtaining approval from insurance payors before delivering certain medical services, treatments, or prescriptions to ensure that they are medically necessary and covered under the patient’s insurance plan.
Importance of Prior Authorization in RCM:
- Reduces Denials: Proper handling of the prior authorization process can significantly reduce the number of denied claims, helping healthcare providers maintain a steady revenue flow.
- Improves Cash Flow: By ensuring that services are pre-approved by payors, RCM companies can help providers avoid unpaid claims and maintain better cash flow.
- Enhances Compliance: Managing the complex requirements of different insurers for prior authorizations ensures compliance with payer policies, reducing the risk of financial penalties.
Role of Technology:
RCM companies leverage automation tools, such as AI and machine learning, to streamline the prior authorization process, reducing manual work and minimizing errors. This leads to faster approvals, fewer delays, and more efficient revenue management.
By managing the entire prior authorization process efficiently, an RCM company helps healthcare providers focus on patient care while ensuring timely and accurate reimbursement.