33 PA Health Care Groups Agree: Reform Insurance Prior Authorization Practices

July 16, 2019

Pennsylvania needs some commonsense reforms to protect against prior authorization red tape that can keep patients from getting the health care they need when they need it.

A coalition of 33 health care organizations that represent Pennsylvania providers (hospitals and 17 different kinds of doctors) as well as patients (people with cancer and 14 other kinds of diseases) agree.

Why this matters:  Most health plans require patients to get approval, called prior authorization, for certain kinds of medications, tests, procedures, and treatments. This approval process can delay or even deny patients’ access to crucial health care services.

One form of prior authorization, called “step therapy,” requires patients to try—and fail to improve with—one or more (typically) less expensive medications before health plans will cover the (typically) more expensive treatments originally prescribed.

What doctors say:  Here’s what physicians say about the impact of prior authorization on their patients, from the American Medical Association’s (AMA) 2017 survey about the topic.

What patients say:  “How long does a patient with cancer have to wait for treatment?” asked a resident of Johnstown, Pennsylvania. This patient was just one of many who shared their concerns with the Pennsylvania Medical Society.

Yes, but:  Insurers explain their use of prior authorization as a way to make sure patients’ health care is necessary and appropriate. Encouraging the wise use of health care resources is a good and very necessary endeavor. The question is: do complex, out-of-date, clinically unnecessary prior authorization requirements accomplish that?

Actually, America’s Health Insurance Plans—the national organization that represents health insurers—is are on record with a consensus statement about improving the situation.

It gets even more complicated:  Even when a patient’s surgery or other treatment is “prior authorized” by an insurer, authorization can be revoked after the fact. Such reversals can leave patients without coverage and doctors, hospitals, and other providers without payment.

During surgery, for example, the surgeon and care team will do what’s needed to give their patient the best possible results. That may mean providing medical care that’s necessary, but different from what was previously authorized. As a result, the patient’s insurer could refuse to cover some or all of the care received—or pay providers.

And then there’s the red tape:  Prior authorization adds to the mountain of paperwork that takes doctors away from their patients, as shown by this information from the 2017 AMA survey.

What’s the fix?  Fourteen states have already enacted reforms to improve the prior authorization process. Now Pennsylvania is beginning to consider legislation (House Bill 1194) to provide common sense protections that would require insurers to:

• Make timely decisions, especially after business hours and on weekends
• Use step therapy protocols based on clinical guidelines developed by independent experts
• Cover and pay claims for care that could not be pre-authorized because it became necessary during the course of a pre-authorized test, treatment, or procedure
• Share publically on their websites percentages of prior-authorization approvals and denials by type of insurance for Pennsylvania