ARTICLE
Described as “an important, safe care tool adopted by health plans and government-sponsored health care programs to help ensure patients receive the best results, better outcomes and better efficiencies”, bipartisan legislation to ease the burden of prior authorization is expected to be introduced in the House this summer. Specifically, prior authorization "prevents the overuse [of care], misuse [of care], or unnecessary (or potentially harmful) care and offers consistency and value to the patient, when there could be a wide variation provider performance, cost of the drug, and/or utilization within a clinician's practice," the spokeswoman said. “[It also] ensures care is consistent with evidence-based practices." Only about 15% of healthcare services require prior authorization. But there is still work to be done to improve the process. America's Health Insurance Plans (AHIP), a trade group here for health insurers, is coordinating a demonstration project to automate prior authorization. Adding that AHIP “supports legislation that is designed to streamline and standardize electronic prior authorization, improve transparency, and encourage best practices that improve care coordination and reduce provider burden.” A healthcare advisor to Rep. Roger Marshall, MD (R-Kan.), an ob/gyn, reported that “we've been working with [Reps.] Mike Kelly (R-Pa.) and Suzan DelBene (D-Wash.) on prior authorization. So the three members hopefully will be introducing that later this summer." Kelly and DelBene are remembers ofthe House Ways & Means Committee, which would likely have jurisdiction over any prior authorization bill. During the last Congress, Kelly introduced the Prior Authorization Process Improvement Act, which was referred to the Ways & Means committee but got no further. That bill required the Secretary of Health and Human Services to submit a report to Congress within a year "on the feasibility of Medicare Advantage organizations and providers and suppliers of services ... using certain technologies to facilitate the administration of prior authorization requirements under Medicare Advantage (MA) plans offered by such organizations." While the three lawmakers work on that bill, other activities related to prior authorization are continuing. In March, the eHealth Initiative, a coalition of provider and healthcare industry organizations, issued a paper on "Considerations for Improving Prior Authorization in Healthcare." The document included four central points: Transparency of payer policy and evidence-based clinical guidelines available at the point of care may, in many cases, reduce the need for prior authorization and minimize care delays. Reducing the overall volume of services and drugs requiring prior authorization could decrease administrative burdens and costs for all stakeholders. Payers, healthcare professionals, and vendors should use existing, industry-endorsed standards whenever possible and explore incorporating new electronic standards that have the capability to improve the prior authorization process. Payers and healthcare professionals should explore alternative payment models that promote bundled authorization for procedures, medications, and durable medical equipment that are associated with a particular episode of care. Over at the Centers for Medicare & Medicaid Services (CMS), the agency is participating in two different workgroups for its Document Requirement Lookup Services Initiative, which is aimed at making it easier for Medicare fee-for-service providers to find out what documentation is required in order for Medicare to approve a particular service for coverage. “CMS is helping define the requirements and architect the standards-based solutions," the agency said. “ n parallel, CMS is preparing to support pilots testing the information exchanges for Medicare fee-for-service programs and possibly coordinate pilots with volunteer participants to verify and test the new Fast Healthcare Interoperability Resource (FHIR)-based solutions." Source: https://www.medpagetoday.com/practicemanagement/reimbursement/79314
Described as “an important, safe care tool adopted by health plans and government-sponsored health care programs to help ensure patients receive the best results, better outcomes and better efficiencies”, bipartisan legislation to ease the burden of prior authorization is expected to be introduced in the House this summer.
Specifically, prior authorization "prevents the overuse [of care], misuse [of care], or unnecessary (or potentially harmful) care and offers consistency and value to the patient, when there could be a wide variation provider performance, cost of the drug, and/or utilization within a clinician's practice," the spokeswoman said. “[It also] ensures care is consistent with evidence-based practices." Only about 15% of healthcare services require prior authorization.
But there is still work to be done to improve the process. America's Health Insurance Plans (AHIP), a trade group here for health insurers, is coordinating a demonstration project to automate prior authorization. Adding that AHIP “supports legislation that is designed to streamline and standardize electronic prior authorization, improve transparency, and encourage best practices that improve care coordination and reduce provider burden.”
A healthcare advisor to Rep. Roger Marshall, MD (R-Kan.), an ob/gyn, reported that “we've been working with [Reps.] Mike Kelly (R-Pa.) and Suzan DelBene (D-Wash.) on prior authorization. So the three members hopefully will be introducing that later this summer." Kelly and DelBene are remembers ofthe House Ways & Means Committee, which would likely have jurisdiction over any prior authorization bill.
During the last Congress, Kelly introduced the Prior Authorization Process Improvement Act, which was referred to the Ways & Means committee but got no further. That bill required the Secretary of Health and Human Services to submit a report to Congress within a year "on the feasibility of Medicare Advantage organizations and providers and suppliers of services ... using certain technologies to facilitate the administration of prior authorization requirements under Medicare Advantage (MA) plans offered by such organizations."
While the three lawmakers work on that bill, other activities related to prior authorization are continuing. In March, the eHealth Initiative, a coalition of provider and healthcare industry organizations, issued a paper on "Considerations for Improving Prior Authorization in Healthcare." The document included four central points:
Transparency of payer policy and evidence-based clinical guidelines available at the point of care may, in many cases, reduce the need for prior authorization and minimize care delays.
Reducing the overall volume of services and drugs requiring prior authorization could decrease administrative burdens and costs for all stakeholders.
Payers, healthcare professionals, and vendors should use existing, industry-endorsed standards whenever possible and explore incorporating new electronic standards that have the capability to improve the prior authorization process.
Payers and healthcare professionals should explore alternative payment models that promote bundled authorization for procedures, medications, and durable medical equipment that are associated with a particular episode of care.
Over at the Centers for Medicare & Medicaid Services (CMS), the agency is participating in two different workgroups for its Document Requirement Lookup Services Initiative, which is aimed at making it easier for Medicare fee-for-service providers to find out what documentation is required in order for Medicare to approve a particular service for coverage.
“CMS is helping define the requirements and architect the standards-based solutions," the agency said. “ n parallel, CMS is preparing to support pilots testing the information exchanges for Medicare fee-for-service programs and possibly coordinate pilots with volunteer participants to verify and test the new Fast Healthcare Interoperability Resource (FHIR)-based solutions."
Source: https://www.medpagetoday.com/practicemanagement/reimbursement/79314