The American Hospital Association (AHA) is asking to mandate waiving the administrative process during public health emergencies (PHE) as patients suffer from delays in care.
While CMS encouraged MA plans to waive the administrative process during the COVID-19 pandemic, the AHA detailed in a letter to CMS administrator Chiquita Brooks-LaSure the importance of working with Congress on a mandate to avoid similar pitfalls as experienced in the past two years.
"The continued use of prior authorization and other health plan utilization management policies by some plans throughout the pandemic exacerbated capacity issues, caused delays affecting patient care, and resulted in high rates of inappropriate denials," the AHA stated.
Concerns over prior authorization and its potential negative effects on patient care and costs to health systems are longstanding. During PHEs, however, the impact can be far more damaging as timeliness becomes a priority.
During the pandemic, the AHA noted that hospitals have faced challenges in quickly turning over hospital beds for higher-need COVID-19 patients, while transferring patients who require post-acute care (PAC) to the appropriate clinical pathways, such as long-term care hospitals (LTCH) or inpatient rehabilitation facilities.
When prior authorization was not waived in these instances, it often resulted in patients forcibly staying in acute care settings as they awaited discharge and beds not being given to higher-need patients.
The AHA also cited inconsistent use of prior authorization during the pandemic, as some plans waived the process during the initial stages before expiration, while other waivers excluded certain provider services.
According to the AHA, MA plans offered less flexibility with waivers compared to Medicaid plans, even when certain insurers operated both a MA and Medicaid plan. MA plans that did not waive prior authorizations during the pandemic took approximately three days to respond to a request for PAC, based on AHA's members estimate, with the total turnaround time potentially increasing by several days for denials and appeals processes.
Speaking to a larger trend, the AHA pointed to one multi-state member reporting that MA prior authorization denial rates for their LTCHs were significantly higher in 2021 and 2022, compared to before pandemic. Though CMS encouraged MA plans to relax prior authorization requirements, some plans have seemingly gone the opposite direction with an increase in denials.
Additionally, the AHA highlighted the strain that prior authorization places on physicians and staff. On average, physicians spend two business days handling prior authorization requests, with 88% reporting the burden caused by the process to be high or extremely high, according to a survey conducted by the American Medical Association.
"Prior authorization processes have exacerbated workforce challenges and contributed to physician and other staff burnout during the PHE," the AHA wrote. "Hospitals often have multiple full-time employees whose sole role is to manage health plan prior authorization requests. These staff often are physicians and nurses who have been diverted from patient care."
While the AHA recognizes the utility of prior authorizations, it concluded in the letter that MA plans would substantially improve pandemic responses through prior authorization waivers.
"Urgent and continued action is needed to ensure that health plans' administrative processes do not impede patients' ability to receive timely, quality, medically necessary care in clinically appropriate downstream settings," the AHA said. "This is more important than ever as we continue into our third year of a global pandemic, fighting new variants and surges, administering additional vaccine doses, addressing workforce shortages, and maintaining critical testing and treatment capacity."
Jay Asser is the contributing editor for strategy at HealthLeaders.