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Commenting for this proposal will be open until the close of business on Monday, June 5.

Title of Proposal:

Resolution on Prior Authorization

On behalf of:       

Richmond Academy of Medicine

Describe the Idea or Issue:

Prescription prior authorization is a health plan cost-control process requiring providers to obtain approval before prescribing medications, which most often requires hours of uncompensated physician and staff work.  Private offices and hospitals employ numerous people to cope with the added burdens of required prescription prior-authorizations which adds to overall health care costs.  In addition, the lengthy processes may have negative consequences for patient outcomes when medications are delayed.

In 2015 (with the help of the Medical Society of Virginia), Governor Terry McAuliffe signed a bill which was meant to improve transparency, uniformity and efficiency in the current prescription prior authorization process. Despite the current law existing, insurers still drag their collective feet when physicians try to settle prior authorization matters in a timely way for their patients. The current prior-authorization appeals process is arduous and oft impossible with the following common practices occurring:

  • Many appeals (unless “urgent”) take months to get a decision because most health plans don’t acknowledge receipt of appeal and often claim to not have received the appeal even though a fax confirmation exists;
  • Initial authorization requests are directed through an off-shore call center slowing down the authorization because of language barriers.
  • Some health plans require a written authorization from the patient in order to do an appeal, which is often required for medical services as well which slows down the process
  • When trying to get a drug authorized that is non-formulary, the health plan isn’t required to do a tier exception and the costs of the drug can be outrageous.
  • Generic drugs can be as expensive or more expensive than some brand name drugs
  • Health plans are requiring physicians to go through the prior authorization process to screen for contraindications, not trusting that the physician (and the pharmacy) is properly screening the patient

Desired Outcome:

The Richmond Academy of Medicine would like the Medical Society of Virginia to continue to work with Insurers and request they be more open and transparent about their approval (and rejection) processes and demand that they release information identifying the common evidence-based parameters for insurers’ approval of the 10 most frequently prescribed chronic disease management prescription drugs, as required by the 2015 law.

We would also like the Medical Society of Virginia to work with the General Assembly to push insurance companies to upgrade the electronic approval of prescription requests, which has been shown to bring cost savings in other states within a few years of its implementation.

And finally, we ask that the Medical Society of Virginia join the American Medical Association to aid in prior-authorization reform with a goal of building a dialogue between providers, health plans and their third parties to cut out needless administrative waste from the system.

Background/Supporting Information contained in Appendix.

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Comments

I strongly support this reform/bill.  Keep up the good work and ty for your time and commitment to helping our patients.

 

Rick Lee MD

Lynchburg

What benefit is this to patietns?

Pre-authorization delays care and adds burdensome work to physicians and then..."does not guarantee payment for this service"

Repel it

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