AMA and Partners Release General Principles to Reform Prior Authorization Requirements

2017-01-26 | CSRO

The utilization-management (UM) requirements that can consume a lot of time for physicians and their staff can be redesigned to make them more clinically important and completed in a more sufficient manner. This is the message relayed by a specific set of principles laid out by the American Medical Association and a coalition of physicians, medical groups, hospitals, pharmacists and patients.

Hours upon hours of practice time can become bogged in prior-authorization requirements, studies have shown. To slash this administrative burden on physicians and protect their patients, the American Medical Association produced 21 principles to direct reform of UM programs, including prior-authorization and step therapy requirements.

These 21 principles are divided amongst five broad rules for proper care:

Clinical Validity. This includes concepts such as UM criteria being based on up-to-date clinical reasoning and never costs alone. This exemplifies the need for patient-specific concerns and flexibility.

Continuity of Care. This rule ensures that patient care is not disrupted by prior-authorization requirements. During review for authorization, any medical treatment should not be interrupted while the UM requirements are addressed.

Transparency and Fairness. This rule addresses the need for detailed clinical explanations for denials and transparency of all restrictions in a searchable, electronic format. Patient-specific, electronic health records can further good reform.

Timely Access and Administrative Efficiency. This rule establishes adequate response times for UM decisions and seeks health plans’ acceptance of electronic prior authorizations. Reliability is important between the insurer and their physicians and patients.

Alternatives and Exemptions. If necessary for certain cases, this rule asks that health plans come with an alternative to prior authorization. Contracts to participate in a financial risk-sharing payment plan should be exempt from prior authorization and step-therapy requirements for services covered under the plan’s benefits.

To see more information on how physicians can handle prior authorization issues, please visit the AMA website. Policy reform has been ongoing in many states to help patients overcome burdensome UM requirements, with Delaware and Ohio most recently addressing the issue.

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