Prior Authorization in Physician Crosshairs
Longstanding insurer review process is also under government scrutiny and on the verge of dramatic legislative change
By Howard Wolinsky
PRIOR AUTHORIZATION, the process of insurers reviewing requests for hospital admissions and medications, has come under increasing government scrutiny as physicians and their organizations say the mechanism has delayed needed treatment and put patient health in jeopardy while wasting physician time to jump through hoops and adding to physician burnout.
The Accreditation Council for Medical Affairs (ACMA), which certifies prior authorization specialists, said the process came into play in the 1960s with the introduction of utilization review with legislation for Medicare health insurance for the elderly and Medicaid, the state and federally sponsored coverage for the poor, primarily to verify the need for hospital treatments and to control costs.
The concept spread to insurance companies, especially pharmacy benefit management (PBM) companies, using prior authorization to determine which medications are worth reimbursing, again to control costs and to determine which medications are appropriate. ACMA notes that prior authorization is used by commercial health plans, self-insured employer plans, union plans, Medicare Part D prescription coverage plans, the Federal Employees Health Benefits Program, state government employee plans, managed Medicaid plans, and others.
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