Fixing Prior Authorization

Author: Jordan Johnson

CMS has let it be known that a major focus in 2020 will be to fix the prior authorization epidemic. The data clearly shows that the delays and denials caused by the current processes are adding unnecessary cost and stress to the care path. These costs are incurred by staff that must navigate complex prior authorization pathways and work appeals for often the same medications and tests over and over. Other cost burdens are created in delays of the actual patients care. These include sub-optimal prescriptions, procedures or treatments that only payors will cover. However, the patients often present with increased side effects or complications which consume more medical resources and supplies. This increases the cost for the patient care path.

Yesterday at the American Medical Association’s National Advocacy Day, Seema Verma comment that fixing this issue is still a top priority. She did not go into detail on the “how,” but did reassure that all the feedback from listening sessions were being reviewed for a solution. According to Seema Verma, "The Trump administration is once again ready to take action to support doctors and patients and we will reduce administrative waste, increase patient safety and free physicians to spend time caring for their patients."

The frustration is that the solutions seem to be clear in some instances and scenarios. There is no doubt that data shows there has been intentional fraud and abuse and some things have been done and billed for monetary gain and not for true clinical value. With that said there are plenty of longstanding proven treatment approaches and care delivery pathways.

In radiation oncology for example, disease sites, identified with a specific CPT® code, are treated based on protocols. These treatment approaches and protocols encompass the exact same CPT® codes with very little deviation or variability. So, why is there so much gate keeping being done to restrict. This is a simple standard deviation plot. The outcomes data, claims data, and clinical data is easily mapped showing this. Legion Healthcare Partners offers Claim Health that provides this service. The proposed RO-APM is a great approach except it is for Medicare only, which doesn’t require prior authorization. The patient’s treatment should not be dictated by the payor. The restriction is costly and unwarranted. CMS can’t identify that 25% of healthcare spend is waste, when part of the spend is due to the unnecessary burden of prior authorization. This is what they are aiming to fix with their initiatives.

Pharmacy and chemotherapy are no different for many diseases and sicknesses. Certain drug or drug combinations are given based on evidence and outcomes data. Patients’ should not have to wait days to get critical medications. The fact that pharma may have a “charging” issue is a different issue that will require a different level of accountability from CMS.

The Texas Medical Association recently surveyed 800 people regarding denials. 24% of these people indicated that their doctor’s orders were denied. In the story Dr. Debra Patt with Texas Oncology highlights the problems many patients and providers are experiencing “ …Lomax's insurance gave prior approval to use the drug Thursday. Her cancer spread to her brain weeks ago. She started radiation treatment almost immediately. “Very risky – like if we could’ve started two weeks ago [with the drug], then we could’ve started two weeks ago," Lomax said. Patt says she has to fight with prior authorization policies regularly. "In my time practicing in Texas, 13 years, I used to be able to give chemo in a day or two," Patt, the executive vice president of Texas Oncology, said. "Now, I have to wait longer than a week because it takes so long to have chemo approved even for common cancers." Patt argues that the time it takes to approve a drug or treatment or something she orders for a patient means their health issue can get worse before medical professionals can address it.

Patients are more frequently having to make tough decisions and cover the cost of expensive medications, tests and procedures out of pocket. As if this were not bad enough, there has been an increase in retro denials by payors. This means that a test, medication of procedure had prior authorization granted initially, then after a later review it was denied. This is how patients end up with a Surprise Bill. It is well documented that patients, more than ever, are non-compliant with medically advised treatment and medication regimens. This is most often tied to their coverage and ability to “afford” the test or medication.

The solution that will most likely be taken is automation. This is a step in the right direction, but if the stakeholders and clinical experts are not involved it could prove to be even more costly for hospitals and practices. A system could easily be targeted for low variability medication delivery, treatment approaches and tests for specific disease sites to grant approval. The data is there to do this. The big question that remains is what about:

  • Medicaid
  • Medicare advantage plans
  • Private payors

This must be a crosscutting solution not an isolated approach. The variability in what each payor requests, wants or will approve has turned into a “moving target game.” There will no doubt be resistance based on a common denominator money/earnings. The data and transparency will expose the good bad and ugly, but CMS’ level of commitment to the cause needs to remain steadfast.

The Patients Over Paperwork initiative is needed if providers are to meet the accountability and constraints placed on the. With that said it CANNOT come at the expense of patients.

Addressing prior authorization with the ONC Interoperability Rule should help us delivery the best care to patients without costly restrictions and delays. This is what value-based care is all about.

Clinical and financial data streams are essential and the Trump administration’s transparency initiative will also parallel and benefit the prior authorization initiative. The transparency portion will begin in January 2021, which will require the publication of private negotiated rates.

Legion Healthcare Partners has the ONLY solution that identifies both claims accuracy and the RO-APM impact with Claim Health.


Jordan Johnson

Contact us to discuss consulting or schedule a demo of ClaimHealth. or 318-537-1509

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