• About Us
    • Contact Us
    • Login
    • ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
About Us Contact Us Login ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
Your Practice

On the Way to Removing Prior Authorization Roadblocks

image_pdfFavoriteLoadingFavorite

Prior authorization is defined as “approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan”.  It is also known as precertification, pre-authorization, prior approval, and predetermination. The premise of prior authorization is for insurance companies to determine if a prescribed product or service will be covered. The process is often bogged down with lengthy, intricate steps that often delay patient care. Several medical, hospital, and insurance associations in 2018 issued a consensus statement that clearly delineated the need for reforms to reduce prior authorization burdens and promote patient-centered care. Recently in response, some states have enacted or have considered enacting legislation to streamline or eliminate prior authorization in some cases.

First, in September 2021 Texas enacted a law that allows prescribers to earn a “gold card” exemption from prior authorization requirements based on their track record of previous prior authorization approvals from insurers including Medicaid managed care organizations and health maintenance organizations (HMOs). If a provider achieves a 90% approval rate on prior authorizations, then it earns a one “rolling approval” for ordering the same drug or test. Another key feature of the law is that physicians must have the opportunity to speak to a Texas licensed physician of same or similar specialty during the prior authorization process.

Another state, California, has passed a bill that prohibits health care insurers that already cover biomarker testing from requiring prior authorization for patients with advanced stage cancer. Eliminating this requirement means that deadly treatment delays due to prior authorization roadblocks are ended.

Legislation, however, is not the only avenue to removing or limiting the prior authorization process. States can remove prior authorization for medications in their Medicaid programs through informal regulatory actions, such as removing authorization requirements on the fee-for-service preferred drug list or by issuing guidance. Attorney generals across the US have urged insurers to remove prior authorization requirements for opioid use disorder medications. Roadblocks to timely care that lead to poor clinical outcomes should continue to fall by the wayside.

Learn More – Primary Resources

Prior Authorization – HealthCare.gov Glossary | HealthCare.gov

Consensus Statement on Improving the Prior Authorization Process

Bill Text – SB-535 Biomarker testing. (ca.gov)

Texas House Bill 3459

Prior Authorization: Overwhelming Burden and Critical Need for Reform

Influence of payer coverage and out-of-pocket costs on ordering of NGS panel tests for hereditary cancer in diverse settings

Want to stay on top of key guidelines and research papers?

ObGFirst® – Try It Free! »

image_pdfFavoriteLoadingFavorite
< Previous
All Your Practice Posts
Next >

Related ObG Topics:

Prior Authorization Negatively Impacts Clinical Outcomes
Notes from the Field: Physician Concern Regarding Prior Authorization and Risk of Serious Adverse Outcomes
Does Prior Authorization Impede Breast Cancer Care?

Sections

  • COVID-19
  • Alerts
  • OB
  • GYN
    • GYN
    • Sexual Health
  • 2T US Atlas
  • The Genome
  • Primary Care
  • Your Practice
  • Grand Rounds
  • My Bookshelf
  • Now@ObG
  • Media

Are you an
ObG Insider?

Get specially curated clinical summaries delivered to your inbox every week for free

  • Site Map/
  • © ObG Project/
  • Terms and Conditions/
  • Privacy/
  • Contact Us/
© ObG Project
SSL Certificate


  • Already an ObGFirst Member?
    Welcome back

    Log In

    Want to sign up?
    Get guideline notifications
    CME Included

    Sign Up

Download Your ObG App
HERE!

Sign In

Lost your password?

Sign Up for ObGFirst and Stay Ahead

  • - Professional guideline notifications
  • - Daily summary of a clinically relevant
    research paper
  • - Includes 1 hour of CME every month

ObGFirst Free Trial

Already a Member of ObGFirst®?

Please log in to ObGFirst to access the 2T US Atlas

Password Trouble?

Not an ObGFirst® Member Yet?

  • - Access 2T US Atlas
  • - Guideline notifications
  • - Daily research paper summaries
  • - And lots more!
ObGFirst Free Trial

Media - Internet

Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Jointly provided by

NOT ENOUGH CME HOURS

It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan

Subscribe

JOIN OBGFIRST AND GET CME/CE CREDITS

One of the benefits of an ObGFirst subscription is the ability to earn CME/CE credits from the ObG entries you read. Tap the button to learn more about ObGFirst

Learn More
Leaving ObG Website

You are now leaving the ObG website and on your way to PRIORITY at UCSF, an independent website. Therefore, we are not responsible for the content or availability of this site