States address payer interference with physicians' orders

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 info@aacuweb.org for more information. 

In nearly every survey of physician sentiment, doctors cite administrative burdens associated with payer relations as distracting from patient care and the performance of their chosen profession. Rather than devote hours each day to non-clinical paperwork, many physicians choose to leave independent practice so they can once again devote their energies to the art and science of medicine.

Professional organizations such as the AACU promote laws and regulations that limit administrative burdens, protect the sacrosanct doctor-patient relationship, and hopefully pre-empt the need for physicians to make that decision. 

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The national “time cost” to physician practices of interactions with health insurers, including seeking prior authorization for procedures and medications, is estimated to be between $23 billion and $31 billion annually. There are more than 100 laws related to utilization review in at least 31 states that address diverse components of that process, from required response time to the layout of a printed or electronic form.

NEXT: Success in Virginia

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Having secured uniform prior authorization standards for all payers in states that included California and Oregon in recent years, a highly regarded campaign in Virginia achieved similar success during the 2015 legislative session.

As detailed on the Medical Society of Virginia website, the society and its urologist president, William C. Reha, MD, MBA, "achieved a major victory for all physicians and patients in Virginia requiring health plans' adherence to the following prescription prior authorization reforms:

• Urgency. Requires a 24-hour turnaround on prior authorization requests for urgent medical needs.

• Timely response. Establishes a deadline of two business days for health plans to act on a non-urgent prescription prior authorization requests.

• Interoperability. Requires that health plans accept electronic prescription prior authorizations that can be transmitted by electronic medical record, e-prescribing, or health information exchange.

• Accountability. Health plans must provide a reason when denying a prior authorization request for a prescription.

• Stability. Requires health plans to honor an approved prior authorization from a patient’s previous health plan for at least 30 days when a patient switches plans.

• Transparency. Formularies, medications subject to prior authorization, prior authorization procedures, and all prior authorization forms must be located in one place on the health plan’s website. Providers will be given a tracking number when requested so they can track the status of their requests.

• Continues the conversation. Establishes a workgroup with physician and health plan representatives to discuss and bring data forward on mental health, chronic care management, and generic medications and improvements to the prior authorization process for those medications."

A cornerstone in the Medical Society of Virginia’s ultimate success was laid when it secured support from myriad stakeholders, including industry groups and state specialty societies. The Virginia Urological Society was pleased to join colleagues from across the Commonwealth to achieve this tremendous victory. One industry observer noted, "If I could clone one initiative… to move positive [electronic prior authorization] language in legislation, it would have to be Virginia SB 1262 and its companion, HB 1942."

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Unfortunately, many other attempts to reduce administrative burdens failed in 2015. Legislation concerning prior authorization can be generally divided in two categories: developing a uniform prior authorization form to streamline the process and reduce some of the administrative burden; and adding additional transparency to the prior authorization process so regulators and patients can better understand how and when determinations are made.

Full-scale streamlining campaigns failed in Maryland, New York, and Texas. These initiatives frequently became mired in the details of each payer's policy and those insurance companies protesting all or part of the complex bills. On the transparency side, the only success came in South Dakota, where SB 118 required that insurers clearly communicate various terms and conditions of prescription drug plans, "including preauthorization review." Similar bills in Rhode Island, Connecticut, Arkansas, Florida, Hawaii, and Iowa each failed to secure favorable consideration in their respective legislatures.

NEXT: A troubling trend

Outside of the legislative arena, in states where uniform prior authorization laws are already on the books, physicians report a troubling trend. Insurers increasingly exploit a loophole that allows them to reject a practice's initial "short form" submission and request additional information. Lawmakers expected such requests would be few and far between, but with their backs to the wall, insurers are pushing back and rebuilding barriers to prescribed medication.

Similarly, on the "fail first" front, insurers intrude upon the doctor-patient relationship by altering providers' orders under the guise of cost savings. As of July 2015, 12 states imposed limits on what payers prefer to call "step therapy." Rather than outlaw the practice altogether, these laws usually exempt certain patients and conditions from having to fail to respond to an insurer's alternative to a prescribed medication before the physician's recommended therapy is dispersed.

Legislators in another 10 states considered such proposals in 2015, with Maine's proposal getting the closest to becoming law. Unfortunately, after securing approval in both the state House and Senate, Gov. Paul LePage (R) vetoed the measure. Montana residents will soon be the happy and healthier beneficiaries of some protection thanks to a bill signed by Gov. Steve Bullock (D) on May 5, 2015, that mandates expedited, impartial, and external consideration of all utilization review requests.

Physicians and patients are rightly frustrated by roadblocks constructed by payers that deny prompt access to vital therapies. Your membership in professional organizations such as the AACU insures that urologists' collective voice on policies that can either increase or decrease the administrative burden of payer relations is heard by lawmakers in the halls of government. Practicing physicians are not without power in these matters, unless they're not plugged in.

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