What is Prior Authorization?
Prior authorization is an approval required by many health insurers before they will cover certain prescriptions, procedures or tests. It’s a process frequently related to step therapy or ‘fail first’ policies, which typically require patients to try a less expensive or generic medication first before covering the original, specific medication a doctor prescribes.
Obtaining a prior authorization can be a time-consuming process for doctors and patients that may lead to unnecessary delays in treatment while they wait for the insurer to determine if it will cover the medication. Further delays occur if coverage is denied and must be appealed. Disputing or appealing a prior authorization request requires a physician to file an appeal – often by mail or fax – which may take several days or weeks to process. Some plans, including plans offered as part of Medicare Part D, are required to respond to a physician within 24 hours for expedited cases. However, the American Medical Association (AMA) reported in a 2006 study that processing prior authorization requests used around 20 hours per week of physician, nurse and clerical staff time. Additionally, a survey by the AMA found that 69 percent of physicians wait several days just to get a response on a prior authorization request for medication.
Because there are few standard procedures or forms for submitting prior authorization requests, confusion and frustration with the process are common among healthcare professionals. A 2012 survey conducted by the Medical Society of the District of Columbia found that 93 percent of surveyed physicians believed that prior authorization protocols had a “very negative” or “somewhat negative” impact on their ability to treat patients.
What can you do?
In many states, there isn’t a uniform process or paperwork to address prior authorization requests, leading to considerable expense in both time and money for doctors, and a potential delay in treatment for patients.
In an effort to achieve a more streamlined and efficient process, several states have introduced or passed legislation to create a uniform application process for prior authorization. For example, in 2010, in response to a request to simplify the prior authorization process, the Minnesota Department of Health produced a unified form for both prescription prior authorization and step therapy exception requests.
Most notable about Minnesota’s law is a stipulation that prior authorization requests must be able to be submitted and accessed electronically by January 1, 2015. Electronic submission in conjunction with a standardized prior authorization process could increase efficiency by eliminating downtime between phone calls, faxes and standard mail.
The value of standardized prior authorization process has been increasingly recognized, with laws being enacted in Michigan and Maryland in 2013. The Maryland Health Progress Act of 2013 includes a provision that requires certain insurers to accept the prior authorization of another insurer. In Massachusetts, work is underway to standardize prior authorization by replacing 150 prior authorization forms with one form.
If you find yourself waiting a long time to get your medication, talk to someone in your doctor’s office to find out the status of the prior authorization and if you can do anything to help. It is important to alert your doctor’s office if there is a delay in the prior authorization to avoid any potential lapse in treatment, as this could affect your health.
- Video: Barriers to Patient Access: Prior Authorization
- Position Statement: Prior Authorization
- Infographic: Prior Authorization Delays Access to Vital Medications
- Infographic: How Prior Authorization Impacts Access to Care
Find out if there is proposed legislation in your state and take action.