NCMS Part of Prior Authorization Reform Effort

AMAThe North Carolina Medical Society (NCMS) is part of a coalition of 15 other health care organizations led by the American Medical Association (AMA) urging health plans, benefit managers and others to reform prior authorization requirements imposed on medical tests, procedures, devices and drugs.

Given the potential barriers that prior authorization can pose to patient-centered care, the coalition is urging an industry-wide reassessment of these programs to align with a newly created set of 21 principles. Prior authorization programs could be improved by applying the principles’ common-sense concepts grouped in five broad categories:

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

Read the 21 principles guiding the coalition’s efforts.

The data entry and administrative tasks associated with prior authorization reduce time available for patients. According to an AMA survey, every week a medical practice completes an average of 37 prior authorization requirements per physician, which takes a physician and their staff an average of 16 hours, or the equivalent of two business days, to process.

The AMA survey illustrates that physician concerns with the undue burdens of preauthorizing medical care have reached a critical level. Highlights from the AMA survey include:

  • Seventy-five percent of surveyed physicians described prior authorization burdens as high or extremely high.
  • More than a third of surveyed physicians reported having staff who work exclusively on prior authorization.
  • Nearly 60 percent of surveyed physicians reported that their practices wait, on average, at least 1 business day for prior authorization decisions—and more than 25 percent of physicians said they wait 3 business days or longer.
  • Nearly 90 percent of surveyed physicians reported that prior authorization sometimes, often, or always delays access to care.

The AMA, along with the NCMS and other coalition organizations are seeking to work collaboratively with health plans and others to create a partnership that lays the foundation for a more efficient prior authorization process.

 
 

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1 Comment

  • Suneya Hogarty, DO

    This is an excellent document! As a rheumatologist, my life and practice is controlled entirely by prior authorizations. My patients suffer and I have 2full time employees just for my practice doing prior authorizations. It is ridiculous! Please keep fighting this fight. I cannot think of 1fight for a medicine that I have not won. Most of the time the denials are completely baseless. They often have the wrong diagnosis code or their preferred medicine us not even FDA approved for the condition being treated. It is a farce. And in all my years of fighting and talking with the utilization review’s medical people, there has NEVER been a rheumatologist to speak with.