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AHA Urges Judicious Approach to Regulating Streamlined Prior Authorization

Analysis  |  By Jay Asser  
   March 23, 2022

In a letter to the Office of the National Coordinator for Health Information Technology (ONC), the American Hospital Association (AHA) commented on prior authorization rulemaking.

The AHA is stating its support for streamlined prior authorization to the ONC but wants the division to test any potential changes in standards before applying regulations in the administrative process.

While acknowledging the negative effects prior authorization can have on providers and patients, the AHA urged in a letter to Micky Tripathi, national coordinator for health information technology, that the ONC be cautious as it attempts to create solutions.

In January, the ONC released a request for information to seek comment on electronic prior authorization standards, implementation specifications, and certification criteria to help potential future rulemaking.

"The AHA strongly supports the creation of a useable, scalable, and efficient solution to help reduce prior authorization impacts on patients and providers," the AHA wrote. "However, we urge ONC—in collaboration with CMS—to pilot the technologies and workflows described in the rule prior to taking any regulatory steps, including certification or codification of standards to minimize unintended negative consequences, such as an inadvertent increase in costs or burden in the health care system."

Arguably the most significant deterrent of prior authorization is the potential for delay in care. The AHA cited a recent physician survey conducted by the American Medical Association (AMA) in which 93% of respondents said prior authorization led to delayed patient access to necessary care.

Losing time to the approvals process is not an option for many patients who could be at risk of worsening conditions or serious adverse events like hospitalization, disability, or even death.

Though standardizing prior authorizations could combat those concerns, the AHA also offered additional reform: an increase in oversight over health plans, applying prior authorization to services with high costs, and the requirement that plans process prior authorizations around the clock.

Related: AHA Wants Required Prior Authorization Waivers During PHEs

Providers, meanwhile, face their own set of challenges when it comes to the administrative process. The AHA once again pointed to the AMA physician survey, highlighting that 88% of respondents described the burden associated with prior authorization as high or extremely high.

To both improve patient care and curb provider burnout, the AHA stated their support for the adoption of electronic prior authorization. From strictly a resources perspective, the 2021 CAQH Index found that automation of prior authorizations had a cost savings opportunity of $437 million annually.

Incorporating new technology, however, can be a resource-intensive process for hospitals and providers, the AHA argued. Premature implementation of new solutions that have yet to completed and tested is also a concern.

As such, the AHA recommended that prior authorization solutions be fully developed and tested prior to the creation of any regulations. Pilot testing and real-world analysis would be essential to not only ensure the changes in the process are working as intended but create data that proves to providers that those changes are worthwhile.

Ultimately, improving prior authorization has the potential for widespread benefits, but the method and application require thoughtfulness.

"In order to effectively update and create standard transactions without unduly burdening healthcare payment processes, regulators should approach potential changes judiciously," the AHA concluded. "Any substantial change in the technology and/or standards used in healthcare information exchange should be sufficiently tested to ensure functionality, analyzed to establish projected return on investment, and incorporated according to an appropriate glide path to minimize systematic disruption."

Jay Asser is the contributing editor for strategy at HealthLeaders. 

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