Majority of States Are Developing Prior Authorization Reforms

The American Medical Association (AMA) reported in May that a majority of states are developing legislation to address the pervasive use of Prior Authorization by Health Care insurance carriers. According to the article, nearly 90 prior-authorization reform bills have been considered this legislative session in 30 states (including Arkansas, California, New Jersey, North Carolina, Washington, D.C., and Washington State), and more than a dozen are still on the table for potential passage.

Many of the bills propose prior-authorization reforms to:

• Establish quick response times (24 hours for urgent care, 48 hours for nonurgent care).
• Allow adverse determinations only by a physician licensed in the state and of the same specialty that typically manages the patient’s condition.
• Prohibit retroactive denials if care is preauthorized.
• Make authorization valid for at least 1 year, regardless of dose changes; for those with chronic conditions, the prior authorization should be valid for the length of treatment.
• Require public release of insurers’ prior authorization data by drug and service as it relates to approvals, denials, appeals, wait times, and more.
• Require a new health plan to honor the patient’s prior authorization for at least 90 days.
• Reduce volume through the use of solutions such as prior authorization exemptions or gold-carding programs.

AMA surveys have found that more than 90% of physicians report delays in care because of prior authorization, resulting in negative impacts on patient outcomes. Even more alarmingly, the same survey found that 33% of physicians report that patients have suffered serious adverse events as a result of delays or abandoned care.

To read the full article, see here.

To read the AMA survey see here: AMA Prior Authorization survey