Positive Improvement – Prior Authorization

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Written By: Pele Fischer, JD, Vice President of Policy & Political Affairs and Ingrid Garvey, Associate Vice President of Policy & Political Affairs

A recent policy paper issued by the American Medical Association (AMA) and workgroup partners, highlights the significant barriers that utilization management programs, such as prior authorization, can create for patients by delaying the start or continuation of necessary treatment and negatively affecting patient health outcomes. The very manual, time-consuming processes used in these programs burden providers and divert valuable resources away from direct patient care.

The Arizona Medical Association (ArMA) recognizes the significant administrative burdens and impacts on patient care due to current prior authorization procedures. ArMA is committed to advocating for reforms in the prior authorization process to ensure efficiency, transparency, and optimal patient care.

During this year’s special session regarding the opioid epidemic, ArMA’s advocacy team worked with the governor’s office to achieve the enactment of much needed prior authorization reforms in The Arizona Opioid Epidemic Act  (Act) related to acute pain, chronic pain and opioid use disorder to ensure these patients have timely access to appropriate care and treatment.

Prior to the Act, Arizona had no legislative requirements concerning the prior authorization process except for emergency services.  These legislation changes include the following transparency and efficiency requirements for a prior authorization regarding acute pain, chronic pain, and opioid use disorder.

  • Health plans must cover at least one form of medically-assisted treatment without requiring prior authorization.
  • Health plans must make available a listing of all prior authorization requirements.
    • The listing must clearly identify the specific health care services, drugs or devices to which prior authorization requirements exist, including specific information or documentation that a provider must submit for the prior authorization request to be considered complete.
  • Health plans must allow providers to access the prior authorization request electronically.
  • Health plans must provide at least two forms of access to request a prior authorization and must have emergency after-hours procedures.
  • Establishes maximum timeframes for decisions on prior authorizations:
    • For urgent health care services, the authorization or adverse determination must be no later than five days.
    • For non-urgent health care services, the authorization or adverse determination must be no later than 14 days.
  • Health plans must acknowledge receipt of the prior authorization request.
  • Health plans must notify providers whether the prior authorization request is granted, denied or incomplete.
    • If the request is denied the specific reason for the denial must be included.
    • If the request is incomplete, the provider must have the option to submit additional information. Once the information is submitted the health plan or its utilization review agent has five days to review and respond for urgent requests and 14 days for a non-urgent request.
  • Prior authorization requests are deemed granted if there is a failure to comply with the timeframes.
  • Prior authorization decisions are binding and may not be rescinded once a decision is made.
    • Provides for an exception in cases of fraud or misrepresentation.
  • Allows for an appeal process in cases of denial of a prior authorization request.
  • For prior authorization requests related to a chronic pain condition, health plans must honor a prior authorization approval for an approved drug for six months after the date of the prior authorization was granted or the last day of the enrollee’s coverage under the plan (whichever is earlier).

The information above is a summary of the major provisions of the legislation. The statutes are nuanced and detailed. The statutes in their entirety can be found in The Arizona Opioid Epidemic Act starting on page 5.

This legislation is a small but monumental step in comprehensive prior authorization reform. The health care provider community as a whole has recognized the importance of continued prior authorization reforms as evidenced by the  Consensus Statement on Improving the Prior Authorization Process. Across the board, prior authorization reforms continue to be a priority for ArMA.

Please view the following links for additional information and resources:

https://www.ama-assn.org/practice-management/prior-authorization

https://www.ama-assn.org/prior-authorization-research-reports

 

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