Inefficient payer approval processes fail patients, frustrate docs


“Preauthorization has escalated beyond reason,” according to AACU President Charles McWilliams, MD.

Based on a partnership with Urology Times, articles from the American Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or for more information.


Prior authorization. Preauthorization. Prior approval. Pre-approval. No matter what you call it, these “utilization management” schemes that consume more and more of urologists' days can be redesigned to make them more relevant and more efficient. This is demonstrated by recent attempts to simplify the administrative burden via state law, as well as a set of principles laid out by the American Medical Association and a coalition of physicians, medical groups, hospitals, pharmacists, and patients.

“Preauthorization has escalated beyond reason,” according to AACU President Charles McWilliams, MD. “The list of services that require approval seemingly gets longer every few months. My staff spends at least 30 to 60 minutes for every surgery and medication preauthorization.”

According to a December 2016 survey of 1,000 physicians conducted by the AMA, 90% of respondents reported that the prior authorization process delays access to necessary care. AACU Health Policy Chair Jeffrey Frankel, MD, said, “Prior authorizations are very disruptive to patient care and have, in a big way, allowed insurance companies to practice medicine without a license.”

The AMA survey found that 80% of physicians are “sometimes, often, or always required to repeat [prior authorization] requests for prescriptions when the patient has already been stabilized on a treatment for a chronic condition.”

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“I received such a notice this past August for a patient who had been on the same medication for bone metastases from solid tumors since June 2015,” Dr. Frankel reported. “The insurer subsequently approved coverage, but now wants to assign a penalty of 20% of the drug's cost for 'retro' prior authorization.”

Twenty-six percent of physicians in the AMA survey said that, “in the prior week, they waited 3 business days or more on average to receive prior authorization decisions from health plans.

“The entire process needs to be streamlined,” Dr. Frankel said. “In Washington state, a workgroup is looking at a mandated short response time of 2 to 3 days, after which the drug ordered is filled.”

Likewise, in several state legislatures, bills are being considered to foster greater efficiency. A proposal in the Georgia House of Representatives would apply already enacted prior authorization requirements to pharmacy benefit managers (PBMs), including a 48-hour response mandate (GA HB 35). Florida insurers and PBMs would have to respond to non-urgent requests within 3 days if legislation under consideration in both the state House and Senate becomes law (FL HB 877/SB 530). To protect physicians from exposure to liability, a lawmaker in Hawaii authored a bill specifying that insurers, not health care providers, are liable for civil damages caused by undue delays for prior authorization (HI HB 885).

Next: Direct reform of utilization management programs


The AACU recently joined a national coalition led by the AMA to direct reform of utilization management programs, including prior authorization.

These 21 principles are divided among five broad rules for proper care (see, “Five broad rules for proper care,” below).

In addition to prior authorization processes, these standards were designed to apply to fail-first requirements, as well. Fail-first, euphemistically called “step therapy” by insurers, is “very disruptive to patient care,” according to Dr. Frankel.

“Instead of letting the patient know if a drug is covered or not, the payer insists that alternative medications be tried before it is authorized,” Dr. Frankel added. “This is particularly problematic at the start of the year when many patients have problems obtaining the medications that they are currently using effectively.”

The above-referenced legislation in Florida, as well as a bill in Maryland (MD SB 768), impose transparency requirements on step therapy. A similar provision in both proposals prohibits insurers from adding fail-first changes during a plan year. Maryland is also one of two states that crafted legislation based on a 2016 Georgia law, the Jimmy Carter Cancer Treatment Access Act, that specifically impacts prostate cancer patients (MD HB740/SB919).

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The model bill says that an insurance company cannot insist that patients fail to respond to other treatments before trying a physician's desired course. The law would only apply to health plans that cover the treatment of advanced, metastatic cancer, which typically involves stage IV patients.

The prior authorization process “exemplifies the kind of clerical work that now consumes about half of physicians' time in the office, while less than 30% of the day is spent on direct clinical care,” according to the AMA. “These growing diversions from patient care serve as physicians' biggest source of professional dissatisfaction.”

“If we do not stick with it, the patient loses big time,” Dr. McWilliams said. The AACU, for one, develops innovative tools and promotes comprehensive reforms that empower urologists in their fight against such distractions from patient care.

Next: Five broad rules for proper care


Five broad rules for proper care

Clinical validity. This includes concepts such as utilization management (UM) criteria being based on up-to-date clinical reasoning and never costs alone. This exemplifies the need for patient-specific concerns and flexibility.

Continuity of care. This rule ensures that patient care is not disrupted by prior-authorization requirements. During review for authorization, any medical treatment should not be interrupted while the UM requirements are addressed.

Transparency and fairness. This rule addresses the need for detailed clinical explanations for denials and transparency of all restrictions in a searchable, electronic format. Patient-specific electronic health records can further good reform.

Timely access and administrative efficiency. This rule establishes adequate response times for UM decisions and seeks health plans' acceptance of electronic prior authorizations. Reliability is important between the insurer and their physicians and patients.

Alternatives and exemptions. If necessary for certain cases, this rule asks that health plans come with an alternative to prior authorization. Contracts to participate in a financial risk-sharing payment plan should be exempt from prior authorization and step-therapy requirements for services covered under the plan's benefits.

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