Coalition to reform prior authorization requirements

The Advocacy Council recognizes the huge burden prior authorization’s put on allergy practices; one article states as much as 20 hours per week is attributed to this task. We’ve become aware of a coalition of health care organizations reforming prior authorization requirements and have asked to join. The coalition urges a focus on transparency and also urges health plans to inform providers of treatments requiring prior authorizations in advance. The group hopes to work with America’s Health Insurance Plans (AHIP) and individual carriers to implement the reforms nationwide. The Advocacy Council advocates safe and effective care for our allergy patients.

The coalition developed 21 principles for health plans to use to reform prior authorization requirements. They focus on five broad categories:

  • Clinical validity
  • Continuity of care
  • Transparency and fairness
  • Timely access and administrative efficiency
  • Alternatives and exemptions

They also deal with utilization management and pharmacy issues that address problems allergists experience with prior authorizations. Specifically, the principles address the effectiveness of treatment before cost; overriding step-therapy requirements and appeal of prior denials; a 60-day grace period for patients’ who are stable on current medications while utilization management requirements in new plans are addressed; and the extension of prior authorization approval across the duration of treatment.

The coalition members include the American Medical Association; American Hospital Association; American Academy of Child and Adolescent Psychiatry; American Academy of Dermatology; American College of Cardiology; American College of Rheumatology; American Pharmacists Association; American Society of Clinical Oncology; Arthritis Foundation; Colorado Medical Society; Medical Society of the State of New York; Minnesota Medical Association; North Carolina Medical Society; Ohio State Medical Society; Washington State Medical Society and the Medical Group Management Association.

Advocacy Issue: 
Billing, Coding & Payments