Prior authorization is a utilization management process that requires physicians to obtain approval from insurance companies before prescribing a specific medication or delivering certain types of care.

Prior authorization:

• limits physician time available for patients,
• delays patient care, and
• results in poor health outcomes and high costs.

Physicians spend on average nearly 15 hours per week on prior authorization paperwork totaling 104 days per year.

This time spent on administrative requirements is valuable time taken away from caring for patients.

Prior authorization can significantly delay the care of patients, resulting in poorer outcomes.

In fact, 92% of physicians reported delays in necessary care due to prior authorization and 61% of physicians reported prior authorization negatively affecting clinical outcomes for their patients. Additionally, 66% of prescriptions rejected at the pharmacy were due to prior authorization requirements.

Prior authorization is also costly.

A national study estimated indirect and direct costs for prior authorization were between $23 to $31 billion.¹

Step therapy is another health plan control process. Under step therapy, patients are required to try older, less expensive medications before they “step up” to another medication originally prescribed by a physician in order to contain costs. Only if the drug fails will the original prescription be filled. An insurer may require a patient to try several cheaper drugs and wait for them all to fail before finally agreeing to cover the drug a doctor originally prescribed. This process can take weeks or even months.

Step therapy can be used in conjunction with prior authorization, delaying patient care even longer.

MSV has been working to make changes to state legislation so that thousands of patients across Virginia will no longer be denied or delayed the health care they need due to prior authorization and step therapy.

MSV’s Position on Prior Authorization and Step Therapy

Prior authorization is an unnecessary burden on physicians to be able to provide timely and effective patient care. Patients deserve to have timely access to the medications and treatment prescribed by their physicians.

During the 2019 General Assembly, MSV supported the passing of legislation to reform prior authorization (SB1607) and step therapy (HB2126). Thanks to the efforts of MSV and other partner organizations, the Governor signed into law legislation making necessary changes to protect the doctor-patient relationship and health of patients.

The law reforming prior authorization supports faster patient access to medication by:

• Guaranteeing 24-hour turnaround, including weekends, for emergency cases
• Removing prior authorizations for dosage changes for approved medication
• Allowing for a patient moving insurance companies or insurance plans to maintain their approved medications for 30 days
• Improving access to addiction treatment

The law also removes barriers to physicians’ reimbursements by:

• Ensuring payment for pre-approved surgeries and invasive procedures
• Allowing a physician to be reimbursed without requiring an additional authorization for any appropriate additional medical care provided during an approved procedure

The law reforming step therapy prevents unnecessary delays in patient care by:

• Creating expedient exemption processes for patients with urgent needs already on effective treatments, so that they don’t have to fail step therapy process yet again
• Including a faster, more efficient exemption process when a patient’s situation demands it for medical reasons.

These changes went into effect July 1, 2019.

Having trouble with prior authorization or step therapy? Let MSV know!

Resources

Prior Authorization Infographic | Version for Printing

^{1Casalino, L. P., Nicholson, S., Gans, D. N., Hammons, T., Morra, D., Karrison, T., & Levinson, W. (2009). What Does It Cost Physician Practices To Interact With Health Insurance Plans? A new way of looking at administrative costs—one key point of comparison in debating public and private health reform approaches. Health Affairs, 28(Suppl1), w533-w543.}