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Health Care Leaders Collaborate To Streamline Prior Authorization And Improve Timely Access To Treatment

by AHIP

January 17, 2018

New industry effort will help simplify processes and improve communications for more efficient patient care

WASHINGTON – January 17, 2018 – Physicians, pharmacists, medical groups, hospitals, and health insurance providers are working together to improve prior authorization processes for patients’ medical treatments, also known as pre-approval. This will help patients have access to safe, timely, and affordable care, while reducing administrative burdens for both health care professionals, hospitals and health insurance providers.

If a treatment or prescription requires prior authorization, it must be approved by a health insurance provider beforehand. This is one way health insurance providers help ensure a treatment is safe and supported by scientific evidence. When applied appropriately, these processes help to maximize the value of every dollar spent on coverage and care.

Prior authorization approvals can be burdensome for health care professionals, hospitals, health insurance providers, and patients because the processes vary and can be repetitive. Streamlining approval processes will enhance patient access to timely, appropriate care and minimize potential disruptions. Enhanced transparency and communication also play critical roles in improving prior authorization processes, which underscores the importance of this new effort.

As the first step in this collaboration, the American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), American Medical Association (AMA), American Pharmacists Association (APhA), Blue Cross Blue Shield Association (BCBSA) and Medical Group Management Association (MGMA) have announced a Consensus Statement outlining their shared commitment to industry-wide improvements to prior authorization processes and patient-centered care.

According to the Consensus Statement, these health care leaders will work together to:

  • Reduce the number of health care professionals subject to prior authorization requirements based on their performance, adherence to evidence-based medical practices, or participation in a value-based agreement with the health insurance provider.
  • Regularly review the services and medications that require prior authorization and eliminate requirements for therapies that no longer warrant them.
  • Improve channels of communications between health insurance providers, health care professionals, and patients to minimize care delays and ensure clarity on prior authorization requirements, rationale, and changes.
  • Protect continuity of care for patients who are on an ongoing, active treatment or a stable treatment regimen when there are changes in coverage, health insurance providers or prior authorization requirements.
  • Accelerate industry adoption of national electronic standards for prior authorization and improve transparency of formulary information and coverage restrictions at the point-of-care.

This group of health care leaders is committed to ongoing collaboration to improve the prior authorization process for health care professionals, health insurance providers, and, most importantly, patients. As experience is gained, these processes will be further refined to maximize efficiency and minimize care disruption for patients.

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Association Quotes:

American Hospital Association
“America’s hospitals and health systems are committed to delivering the best care for patients in the most efficient manner, goals we share with our partners in the health field,” said Tom Nickels, executive vice president of the AHA. “These principles provide a good starting point for providers and health plans to work together toward continuous improvement in quality of care and health outcomes while reducing unnecessary administrative burden.”

America’s Health Insurance Plans
“Working together, we can find the right solutions to improve the process, promote quality and affordable health care, and reduce unnecessary burden,” said Richard Bankowitz, M.D., chief medical officer of AHIP.

American Medical Association
“This collaboration among health care professionals and health plans represents a good initial step toward reducing prior authorization burdens for all industry stakeholders and ensuring patients have timely access to optimal care and treatment,” said AMA Chair-elect Jack Resneck, Jr., M.D.

American Pharmacists Association
“We are very supportive of this collaborative effort that is critical to improving patients’ access to needed medical services and medications, promoting continuity of care, and removing provider burdens. Adoption of these principles will free physicians, pharmacists, and others to spend more time in patient care,” said Thomas E. Menighan, EVP & CEO of the APhA.

Blue Cross Blue Shield Association
“By working together, we’re taking an important step forward in alleviating what can be an unnecessary burden for some patients, while ensuring our members continue to receive high quality, safe and effective care,” said Justine Handelman, senior vice president of policy and representation at Blue Cross Blue Shield Association.

Medical Group Management Association
“By forging an agreement addressing an important set of prior authorization challenges, this collaborative is leading the industry toward the dual aim of reducing the volume of required authorizations and decreasing complexity in conducting these transactions,” stated Anders Gilberg, MGMA senior vice president, government affairs.

Media Contacts:

American Hospital Association – Colin Milligan, cmilligan@aha.org, (202) 638-5491
America’s Health Insurance Plans – Cathryn Donaldson, cdonaldson@ahip.org, (202) 861-1479
American Medical Association – Robert J. Mills, robert.mills@ama-assn.org, (312) 464-5970
American Pharmacists Association – Chad Clinton, cclinton@aphanet.org, (202) 429-7558
Blue Cross Blue Shield Association – Tiffany Jungers, tiffany.jungers@bcbsa.com, (202) 626-4792
Medical Group Management Association – Robert Tennant, rtennant@mgma.org, (202) 293-3450

Boiler Plates:

About the American Hospital Association
The AHA is a not-for-profit association of health care provider organizations and individuals that are committed to the improvement of health in their communities. The AHA is the national advocate for its members, which include nearly 5,000 hospitals, health care systems, networks and other providers of care. Founded in 1898, the AHA provides education for health care leaders and is a source of information on health care issues and trends. For more information, visit www.aha.org.

About America’s Health Insurance Plans
America’s Health Insurance Plans (AHIP) is the national association whose members provide coverage for health care and related services to millions of Americans every day. Through these offerings, we improve and protect the health and financial security of consumers, families, businesses, communities and the nation. We are committed to market-based solutions and public-private partnerships that improve affordability, value, access and well-being for consumers. Visit www.ahip.org  Learn more about health insurance and how it works at myhealthplan.guide.

About the American Medical Association
The American Medical Association (AMA) is the premier national organization providing timely, essential resources to empower physicians, residents and medical students to succeed at every phase of their medical lives. Physicians have entrusted the AMA to advance the art and science of medicine and the betterment of public health on behalf of patients for more than 170 years. For more information, visit ama-assn.org.

About the American Pharmacists Association
The American Pharmacists Association, founded in 1852 as the American Pharmaceutical Association, is a 501 (c)(6) organization, representing 64,000 practicing pharmacists, pharmaceutical scientists, student pharmacists, pharmacy technicians and others interested in advancing the profession. APhA is dedicated to helping all pharmacists improve medication use and advance patient care and is the first-established and largest association of pharmacists in the United States. For more information, please visit www.pharmacist.com.

About the Blue Cross and Blue Shield Association
The Blue Cross and Blue Shield Association is a national federation of 36 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively provide health care coverage for one in three Americans. BCBSA provides health care insights through The Health of America Report series and the national BCBS Health Indexsm. For more information on BCBSA and its member companies, please visit BCBS.com. We also encourage you to connect with us on Facebook, check out our videos on YouTube, follow us on Twitter and check out our blog.

About the Medical Group Management Association
The Medical Group Management Association (MGMA) is the premier association for professionals who lead medical practice. Since 1926, through data, people, insights, and advocacy, MGMA empowers medical group practices to innovate and create meaningful change in healthcare. With a membership of more than 40,000 medical practice administrators, executives, and leaders, MGMA represents more than 12,500 organizations of all sizes, types, structures and specialties that deliver almost half of the healthcare in the United States. Learn more at www.mgma.org.