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Potential code for prior authorizations on AMA CPT Editorial Panel meeting agenda

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"Good public and economic policy must align costs, benefits, and incentives; currently, all costs are incurred by physician practices, and all financial savings and benefits from prior authorization accrue to health insurance plans, leading to perverse incentives,” says Alex Shteynshlyuger, MD.

The American Medical Association’s (AMA) Current Procedural Terminology (CPT) Editorial Panel is scheduled to meet May 9 to 11 in Chicago, and its meeting agenda includes 3 potential new CPT codes “to report services (physician, QHP, Clinical Staff) related to [payer] authorization of procedures,” referring to qualified health plans.

What does it say?

Proposals for new codes may come from industry, medical specialty societies, government, health plans, hospitals and others. AMA does not disclose identities of applicants because their requests may have proprietary information.

But the agenda included a file with dozens of studies and documents stating what so many physicians already know: In its current form, prior authorization is a burden that delays patient care – sometimes with bad effects on patient health – while costing medical practices a lot of time and money.

Among the supporting documents:

AMA’s own 2022 provider survey that found 94% reported PA always, often, or sometimes delays access to necessary care. The same survey said 80% of physicians reported PA at least sometimes leads to patients abandoning their treatments.

The Medical Group Management Association’s 2023 survey reporting 89% of medical practices had to hire or redistribute staff to work on PA due to the increase in requests. A full 47% reported hiring full-time equivalent staff to assist with increasing PA requirements.

Gold cards not so golden

Physicians, lawmakers, payers, and others have pondered whether a “gold card” program for medical practices could make the PA process easier for practices that build a record of appropriate patient treatments. But that hasn’t worked so well in Texas, where the Texas Medical Association in December 2023 cited the Texas Department of Insurance figure that just 3% of physicians and other clinicians met the eligibility for that state.

Alex Shteynshlyuger, MD

Alex Shteynshlyuger, MD

Alex Shteynshlyuger, MD, a New York urologist, pointed to that report and said “gold carding failed spectacularly in Texas.”1

In the prior authorization process now, costs accrue to patients and providers, essentially one party, causing severe market inefficiencies. The best solution is to fix the problem equitably and fairly for physicians, other health care providers, and health plans, Shteynshlyuger said.

"Good public and economic policy must align costs, benefits, and incentives; currently, all costs are incurred by physician practices, and all financial savings and benefits from prior authorization accrue to health insurance plans, leading to perverse incentives,” Shteynshlyuger said in an email to Medical Economics. “In the end, there is every incentive not to advocate on the patient's behalf: The plan gets to gain 100% of unspent money as profits; providers avoid losing money on every prior authorization they do and every denial of care or wrongful denial of prior authorization that they submit."

PA has ‘a life of its own’

In 2020, AMA then-President Jack Resneck, MD, told Medical Economics about his experience with prior authorizations.

Jack Resneck, MD

Jack Resneck, MD

“When prior authorization came into being, it was really focused on brand new drugs with very high price tags where the evidence was still accumulating, and maybe where there was variation in care,” he said. “It has gotten to the point where I, as a dermatologist, am literally doing prior auths every day on generic topicals like cortisone products that were invented in the 1960s. So the expansion – and we’ve seen this in the data – has been dramatic. It’s no longer focused on high-cost drugs that are unique or on new drugs. It’s no longer focused on outlier physicians in any way. It really just seems to have taken on a life of its own.”

Reasons for optimism?

Resneck said he was optimistic because at that time, legislators and policy makers were gaining in understanding that the PA process had gotten out of control. His predictions emerged as realities, to a degree, in more recent times. The bill known as the “Improving Seniors’ Timely Access to Care Act,” with provisions to streamline prior authorizations, has strong bipartisan support and passed in the House of Representatives. Lawmakers this year praised the U.S. Centers for Medicare & Medicaid Services for implementing new requirements with the same goals.

By the numbers

The appearance on the agenda does not guarantee any new code will make it into the U.S. health care system.

In February, AMA’s CPT Editorial Panel agenda had 45 proposals for new, revised, add-ons or deletions in CPT codes. Among them, 26 were approved, 4 rejected, and 16 withdrawn.

At the September 2023 meeting, there were 76 proposals; 31 were approved, 13 rejected, 22 withdrawn, and 9 postponed. In May 2023, there were 61 proposals, with 29 approved, 5 rejected, 20 withdrawn, 5 postponed, and 2 terminated, according to the summaries posted on AMA’s website.

REFERENCE

1. Pierce A. Shielding the gold card law: TMA fights to guarantee gold card is implemented as intended. December 2023. Accessed March 7, 2024. https://www.texmed.org/TexasMedicineDetail.aspx?id=63122

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