5 Prior Authorization Updates for Rev Cycle Leaders

Not many regulations have had such a profound impact on patients and organizations like prior authorization requirements.

Prior authorizations involve complex, time-consuming processes which put a huge administrative burden on revenue cycle staff. Not only that, but the requirements for prior authorizations can vary between insurance plans, leading to confusion and additional administrative tasks which can take time away from patient care.

Staying up to date on regulatory changes is key to helping to reduce these burdens for your staff. Here are five recent stories on prior authorizations that revenue cycle leaders can’t miss.

Prior auths 'delay, deny, and disrupt': Major medical societies show support for reform

118 major organizations, spanning from the American Medical Association to The Alaska State Medical Association, sent a letter to CMS urging it to finalize proposed prior authorization reforms that target the inappropriate use of authorization requirements by Medicare Advantage plans which, the organizations say, delay, deny, and disrupt the provision of medically necessary care to patients. Read the story here.

Physicians say prior authorization hurts patient outcomes, wastes resources

The recent poll of 1,001 practicing physicians in December 2022 reveals the ramifications patients and providers have to deal with from health insurers imposing prior authorization practices to control costs.

Nearly nine in 10 respondents (89%) said that the administrative process had a negative impact on patient clinical outcomes, with only 2% answering that it has any positive impact. Read more here.

Hey senate, want to help rev cycle workforce shortages? Reduce prior auth requirements, support tech

The Senate Health, Education, Labor, and Pensions Committee recently published a request for information on the drivers of healthcare workforce shortages and potential solutions. The request garnered responses from several large medical associations with solutions aimed at prior authorization requirement reduction and more support in automation.

When it comes to prior authorizations, the MGMA said in its feedback that in order to address the multi-faceted causes of physician and staff burnout, Congress should examine legislative solutions to ease administrative burden and allow providers to focus on patient care, including prior authorization reform. Read the full story here.

Feds move to rein in prior authorization, a system that harms, frustrates patients

Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.

So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say. Read more here.

Ophthalmologists ask CMS to suspend certain prior auth policies

In recent comments to CMS, the American Academy of Ophthalmology addressed CMS’ proposed rule regarding improving the electronic exchange of healthcare data, particularly in terms of addressing Medicare Advantage prior authorization processes, an area of the rule that the group says has a profound effect on patients. Read the full story here.