Surgeons across the U.S. are facing setbacks in providing services to patients because of stringent prior authorization processes both private insurance companies and the Centers for Medicare & Medicaid Services (CMS) contractors that administer Medicare Advantage health plans have implemented.
Participants in a recent American College of Surgeons (ACS) questionnaire ranked prior authorization as the top administrative burden for surgical practices in 2019. Although utilization review requirements, such as prior authorization, can sometimes play a role in ensuring that patients receive clinically appropriate treatment while controlling costs, many of these requirements are applied to services performed in accordance with a routine, evidence-based plan of care for a given health care condition. Over the past two years, the number of prior authorizations required nationally is estimated to have increased by 27 percent, growing from 143 million in 2016 to 182 million in 2018, according to the Council for Affordable Quality Healthcare Index.1 This cost-control mechanism, which physicians describe as having a negative impact on clinical outcomes and an interference to continuity of care, is increasingly being used by payors as an extra and unnecessary step to obtain coverage and reimbursement for common services that almost always are approved in the end.1,2 Even if a physician completes the prior authorization process and obtains preapproval for a portion or the entirety of the treatment plan, insurers may later deny or retrospectively collect payment for previously authorized services.
As insurers continue to subject a growing number of services to prior authorization, many medical and surgical practices can no longer absorb the costs of complying with these increasingly time-consuming requirements, forcing surgeons and practices to end their contractual relationships with insurers as participants in various health plan networks. When surgeons become out-of-network providers, their patients must either seek care elsewhere or pay out of pocket to continue their course of care, both of which inappropriately delay care at the expense of patients’ health and financial resources.
The College’s perspective is that the federal government needs to intervene quickly to decrease the overwhelming administrative burden of prior authorization requirements and to maintain timely patient access to a range of health care services. The ACS Division of Advocacy and Health Policy (DAHP) has worked to position the College at the forefront of the regulatory relief movement and has developed a number of recommendations described in this article to ease the extraordinary administrative burden of prior authorization and allow surgeons to reinvest their time in what matters most to them—their patients.
While many aspects of the clinical workflow have become automated, prior authorization remains a manual, paper-based task for many physicians. The number and cost of resources that practices devote to prior authorization are attributable to the lack of automated, standardized processes that integrate with electronic health records (EHRs) and other practice management systems. To facilitate uniformity, the ACS recommends that insurers adopt a standard electronic transaction that physicians and facilities can use to ask insurers to review proposed services and obtain authorization for those services. The College also urges insurers to make all prior authorization requirements available online or in EHRs at the point of care to provide physicians with the real-time coverage information they need when making treatment decisions.
In its March 1 comment letter to CMS on methodological changes to 2020 Medicare Advantage and Part D payment policies, the ACS commended the agency’s efforts to prompt all payors, including Medicare Advantage plans, to align their prior authorization processes with recommendations made under the Da Vinci Project—an industry-led initiative to identify and implement care delivery use cases for the exchange of information between health plans and providers.3
CMS noted in the draft call letter that, in support of the Da Vinci Project, it began developing a prototype Medicare Fee-for-Service (FFS) Documentation Requirement Lookup Service (DRLS), which would digitally use the information physicians insert into their EHRs for a specific Medicare FFS beneficiary to determine what, if any, documentation or prior authorization requirements might affect clinical decision making or coverage for that patient. If the DRLS identifies any such requirements, it would automatically respond to the physician through the EHR with the appropriate documentation or prior authorization policies, as well as any related templates the physician should complete and provide to CMS in a claims submission. The agency recommended that payors develop a similar lookup service and populate the tool with their documentation rules and list of items and services that require prior authorization.
The College supported CMS’ message to payors in the draft call letter and agreed that patient and payor data should be leveraged in EHRs to notify physicians of prior authorization and other documentation requirements when a service is ordered. The ACS letter further states that any such integrated solutions should automate prior authorization decisions for routine therapies and prepopulate forms for cases requiring further review. The use of information already stored in EHRs to complete such processes could streamline payor-provider communication, improve the accuracy and efficiency of these administrative tasks, and reduce interruptions in the provision of care.4
In addition to enhancing the interoperability of prior authorization, the ACS has asked CMS to correct the numerous nondigital process flaws associated with this process. We recommend that these issues be addressed through the following actions.
CMS should require Medicare Advantage plans to limit the scope of prior authorization requirements to physician practices that stray from evidence-based medicine or suggest a pattern of overutilization after adjusting for patient population. Prior authorization should not be applied to services that are typical for a specific condition, are part of an ongoing therapy regimen, exhibit low variation in utilization or denial rates, or have been approved previously as part of a patient’s care plan.
Elimination of trivial barriers to payment
Payment for services for which prior authorization was granted should not be denied or rescinded based on billing technicalities. For example, reimbursement should not be withheld when the service performed is clinically comparable to an approved service but is more properly reported using a different Current Procedural Terminology code, when a procedure’s necessity was unanticipated, or the procedure is performed incident to or in the course of an approved operation.
Reasonable resolution of physician and patient grievances with respect to prior authorization requires comprehensive and specific information regarding Medicare Advantage plans’ processes and outcomes. Therefore, CMS should require Medicare Advantage plans to report on the extent to which they use prior authorization and their approval and denial rate by service. This documentation should include the following data as one component of Medicare Advantage’s annual reports to CMS: information about the specific procedures subject to prior authorization, the proportion of each service approved, and the time lapsed from submission until a determination is issued.
Guidance to Medicare Advantage organizations
CMS should issue guidance requiring these plans to follow the set of prior authorization principles endorsed in January 2018 by associations representing managed care plans, including America’s Health Insurance Plans and Blue Cross Blue Shield Association. Such principles, described in the Consensus Statement on Improving the Prior Authorization Process, identified areas that “offer opportunities for improvement in prior authorization programs and processes that, once implemented, can achieve meaningful reform.”5 These policies include, among others, an annual review of services subject to prior authorization and the removal of services from these lists for which prior authorization is unnecessary; protections for continuity of care for patients on appropriate, stable therapy; and the industry-wide adoption of automated processes.
College takes action on Capitol Hill
As part of this year’s Leadership & Advocacy Summit, the ACS convened a panel on the issues associated with prior authorization. Panelists discussed the burdens that physicians are facing, the Capitol Hill perspective, and what insurers are doing to address these issues. To follow up on the concerns addressed in the panel discussion, nearly 300 summit attendees went to Capitol Hill to explain why Congress needs to address the inappropriate application of prior authorization by Medicare Advantage plans. These efforts, in conjunction with supplemental grassroots activities—including a legislative call to action via the American College of Surgeons Professional Association SurgeonsVoice and additional opportunities for surgeon advocates to educate their members of Congress at home—led to the introduction of legislation to bring transparency to Medicare Advantage use of prior authorization requirements.
The ACS has joined with the Regulatory Relief Coalition, a collective of specialty physician organizations, to work with key members of Congress to develop bipartisan solutions that would improve the transparency and efficiency of the prior authorization process in the Medicare Advantage program.
As part of this collaboration, the ACS participated in an effort last year to gain support for a congressional sign-on letter to CMS, requesting that the agency provide guidance to Medicare Advantage plans on the use of prior authorization. More than 100 members of the U.S. Congress signed on to this ACS-supported bipartisan letter, demonstrating that members of Congress are concerned that overuse of prior authorization could result in significant barriers to timely, medically appropriate care. In addition, through the Regulatory Relief Coalition, the ACS has contributed to the development of legislation to address improper Medicare Advantage plan application of prior authorization.
Congress responds with legislation
In June, Reps. Suzan DelBene (D-WA); Mike Kelly (R-PA); Roger Marshall, MD (R-KS); and Ami Bera, MD (D-CA), introduced the Improving Seniors’ Timely Access to Care Act, H.R. 3107. This ACS-supported legislation is modeled on the Consensus Statement on Improving the Prior Authorization Process and is a critical step toward improving the transparency and efficiency of the prior authorization process in the Medicare Advantage program.5
H.R. 3107 would require CMS to regulate the Medicare Advantage plan’s use of prior authorization. The ACS is particularly appreciative of a provision in the bill that would prohibit these plans from requiring prior authorization for any surgical or other invasive procedure if the procedure is furnished during the course of a procedure that already was approved or did not require prior authorization.
Whereas the legislation includes some beneficiary protection standards to ensure continuity of care, the ACS anticipates that this bill will serve as a stepping stone for further patient protections and standardization of prior authorization requirements and processes. Because of the lack of standardized Medicare Advantage plan prior authorization processes, the ACS anticipates that the inclusion of electronic transmission and transaction standards are a step in the right direction. The College is optimistic that the inclusion of these electronic standards will help to facilitate real-time decisions for those services that are routinely approved.
In addition, H.R. 3107 will bring greater transparency by requiring Medicare Advantage plans to report to CMS on the extent of their prior authorization use and the rate of approvals or denials by service and/or prescription medication—thus helping to reduce unnecessary requests and to ensure patient access to timely and medically necessary care.
The ACS continues its efforts to build bipartisan support for this legislation and to advocate for its consideration in the House Committee on Ways and Means.
How can surgeons get involved?
Meeting with lawmakers and demonstrating strength in numbers both in Washington, DC, and at in-district meetings are effective ways to raise awareness about important health care policy priorities. Senators and representatives return to their home states and districts during congressional work periods, and in-district meetings are an opportunity to educate and assist legislators to gauge what issues are of importance to constituents, particularly surgeons and surgical patients. Through the 2019 Advocate at Home Program, DAHP staff facilitated in-district meetings for a number of surgeon advocates. While participants discussed several advocacy issues during these meetings, surgeons highlighted that H.R. 3107 was a priority.
The College has several other federal legislative priorities that have the potential to be considered during the 116th Congress. Surgeons can visit the SurgeonsVoice Advocacy Center to learn more and to identify issues that are important to them and advocate on their profession’s behalf by sending prewritten letters to their members of Congress.
The ACS DAHP encourages surgeons to tell us about their own experiences with prior authorization and its impact on surgical patient care. Feedback from Fellows is essential to the College’s efforts to identify and advocate for the elimination of burdensome requirements through the ACS Stop Overregulating My OR (SOMO) initiative, through which the ACS collaborates with federal agencies and congressional leaders to address policies that are overwhelming surgeons across the country. To share your administrative burden story, contact Lauren Foe, Senior Regulatory Associate, at firstname.lastname@example.org. Visit the SOMO web page to learn more about the College’s regulatory relief successes and advocacy efforts.
- CAQH CORE. Moving forward: Building momentum for end-to-end automation of the prior authorization process. Available at www.caqh.org/sites/default/files/core/white-paper/CAQH-CORE-Automating-Prior-Authorization.pdf. Accessed October 16, 2019.
- American Medical Association. Industry checkup: Measuring progress in improving Prior authorization. Available at: www.ama-assn.org/system/files/2019-03/prior-auth-survey.pdf. Accessed October 16, 2019.
- American College of Surgeons. Comment Letter on Advance Notice of Methodological Changes for Calendar Year (CY) 2020 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2020 Draft Call Letter. Available at: facs.org/-/media/files/advocacy/regulatory/ma_part_d_2020_call_letter_030119.ashx. Accessed October 9, 2019.
- American Medical Association. 2018 AMA prior authorization physician survey. Available at: www.ama-assn.org/system/files/2019-02/prior-auth-2018.pdf. Accessed October 16, 2019.
- American Medical Association. Consensus statement on improving the prior authorization process. Available at: www.ama-assn.org/sites/default/files/media-browser/public/arc-public/prior-authorization-consensus-statement.pdf. Accessed October 9, 2019.