Prior Authorization Elimination
The Richmond Academy of Medicine
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
The Richmond Academy of Medicine requests the Medical Society of Virginia make the elimination of Prior Authorization in Virginia a top legislative priority in 2018. We’d also like to see the Medical Society continue to work with Insurers and PBM’s 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 Advocacy Summit Proposal No. 8 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, the Medical Society of Virginia should join the American Medical Association to aid in priorauthorization 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 and improve patient access to care including diagnostic testing, surgical procedures and medical therapies by eliminating prior authorization in Virginia.
• Principles on Prior Authorization
• Prior Authorization Editorial by Dr. Mark Monahan from 2.11.17 RTD
Background information can be found on pages 46-60 of appendix