Health insurance Prior authorization has long been used as a tool to control spending and promote affordable care, but advocates and policy makers are increasingly pushing its use across all forms of health insurance. It is in the limelight because it asks for close scrutiny.
At Allied Pharmacy, we are committed to doing everything we can to ensure that each patient receives the best possible care.
What is Prior authorization?
Prior authorization (also referred to as “pre-approval” and “pre-authorization”) refers to a medical plan requirement to obtain approval for a medical service or drug prior to the provision of care to a patient. This allows the plan to assess whether care is medically necessary or covered. The criteria for this review are often made by the plan itself, based on medical guidelines, costs, usage, and other information. The process for obtaining pre-approval also varies by insurer, but requires management and clinical submissions by the attending physician and possibly the patient. In a 2021 American Medical Association survey, most physicians (88%) rated this process as high or very high administrative burden. Physicians also noted that prior approval often delays patient care and leads to adverse clinical outcomes. Another independent study in 2019 concluded that previous studies did not provide sufficient evidence to draw conclusions about the health or net economic impact of preauthorization in general. I was.
How often is pre-approval used and what are its implications?
There is little information about how often preapproval is used and for which treatments, how often approval is denied, or how reviews affect patient care and costs. The 2021 KFF Issue Brief found that most (99%) of Medicare Advantage participants have plans that require pre-approval for some services. Additionally, 84% of Medicare Advantage members have plans that require preapproval for mental health services.
A recent report by the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) found that 13% of Medicare Advantage Plan pre-approval denials were for benefits that would otherwise have been covered by Medicare. The OIG cited use of clinical guidelines not included in Medicare’s applicable rules and supervised care plans requiring additional, unnecessary documentation as reasons for inappropriate denials. The OIG recommended that the Centers for Medicare and Medicaid Services (CMS) should further investigate the adequacy of the clinical criteria used in Medicare Advantage Plans in determining coverage, and HHS agreed.
What’s going on now?
Concerns about the use and impact of preapproval by health insurance have led to various measures being considered to regulate or make this practice more transparent.
Clinical application criteria
The health insurance’s use of its own “homemade” clinical criteria to make coverage decisions is under scrutiny. For example, California currently prohibits insurance companies from using their own clinical criteria to determine medical need, instead opting for commonly accepted standards developed by non-profit organizations in relevant clinical specialties. It requires commercial insurers to use standards that are consistent with those set forth in the Note that state laws like these do not apply to employer-sponsored self-insurance plans.
Use for behavioral health
The Mental Health Parity and Addiction Equity Act (MHPAEA) documents preapproved use of both medical and behavioral health care benefits for private insurance companies, employer-sponsored plans, and certain Medicaid plans must be converted. The plan should include a comparative analysis including rationale and evidence for the use of pre-approval and other non-quantitative range limits. Compliance with this requirement has been delayed, but a recent federal agency report to Congress indicated that increased federal and state enforcement would remove pre-approval of certain behavioral therapies based on alleged parity violations. we need a plan.
