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87TH LEGISLATIVE 87TH LEGISLATIVE
SESSION SESSION

Prior Authorization
Continuing, some diagnostic studies and and Sherrod Brown (D-OH). The bill also
some medications deemed inappropriate by seeks to establish an electronic Prior Authori-
Prior the insurance company would also be subject zation (ePA) system in order to approve med- Delays and Undermines
Authorization to Prior Authorization requirements. ical services and prescriptions in a more timely the Best Patient Care
Insurer related shenanigans significantly im-
manner. Reviews by qualified medical person-
Shenanigans pact patients, with interruptions and delays in nel would be required, and beneficiaries would By Jayesh Shah, MD
be protected from disruptions in their care.
treatment being very common. The patient
must figure out whether the process is stalled Here in Texas, the Texas Medical Associa-
By Neal S. Meritz MD because of the doctor, the pharmacy or the in- tion (TMA) has been active in the encourage- tion, it becomes a perfect scenario for the clo- response from the insurance company. 64% of
surance company. Patients are forced to forego ment of Prior Authorization legislation. sure of many solo private practices. If solo pri- physicians reported the wait time of at least
Doctors continue to shoulder the burdens necessary treatments in order to avoid the Governor Greg Abbott signed SB 1742 in vate practices close, again, the access to care one business day, while 29% reported waiting
of the Prior Authorization process, but that Prior Authorization unpleasantness, meaning June, 2018, sponsored by Senator Jose Menen- decreases. The physician's private practice of- at least three business days. I recently testified
might all change if proposed bipartisan legis- treatments must often be abandoned. A survey dez (D-San Antonio). This bill requires fice is the lowest cost center in the complex at an AMA interim meeting that, if insurance
lation becomes law this year. Medical Eco- conducted by the AMA in 2018, reported greater transparency involving Prior Authori- health care system. companies require prior authorizations, they
nomics,, reports that at least 30 to 45 minutes that 92% of doctors agreed that Prior Author- zation procedures, and it mandates that uti- It is critical to advocate and educate our leg- should make staff available 24 X 7 to process
are required to complete each individual Prior ization harms patient access to care by 92%! lization reviews be conducted by a islators on these prior authorization issues. We approvals. This 24-hour availability will at
Authorization, which totals 20 plus hours per Physicians are united in their insistence that Texas-licensed physician in the same specialty have a chance to make a difference. Due to least improve the timing for the decisions and
week per practice. This time is unreimbursed the Prior Authorization system must be re- as the requesting physician. Two physicians in COVID-19, the Texas Medical Association hopefully decrease serious adverse events for
and it is now estimated to cost over $68,000 a formed. The AMA has developed a concerted the Texas State Legislature, Greg Bonnen MD has arranged all first Tuesdays at the Capitol the patients.
year for every practice. It is a labor-intensive program to encourage changes. Minimizing (R-Friendswood) and Dawn Buckingham as virtual events (https://www.texmed.org/ Delays in obtaining prior authorization also
procedure for physicians, as denied requests care delay is crucial, as these frequently result MD (D-Lakeway) have proposed a bill man- FirstTuesdays/). Please use this opportunity to cause problems with discharge planning for
necessitate manual intervention resulting in in potentially unnecessary adverse patient dating that insurers post the health services connect to our legislators, so you can advocate patients. During COVID-19, it becomes a
subsequent practice cost increases. Denials sit events. In addition, the volume of Prior Au- that require Prior Authorization and that ex- on behalf of our patients from the comfort of problem when most hospitals do not have
unworked as they often require multiple let- thorization demands for prescriptions and plain how it works. This includes a list of doc-
As if COVID-19 was not enough to stress your home or office. extra beds, and patients who have to be trans-
ters of documentation and many telephone medical services has steadily increased. Utiliza- umentation the physician must provide.
the health care system, the Prior Authorization There was already a shortage of physicians, ferred to another facility require a quick turn-
conversations. Hold times are staggering, tion management requirements must be ap- Senator Menendez and Representative Julie
(PA) burden is growing and making it difficult but now, due to the global pandemic, the around.
often lasting up to an hour. An authorization plied by insurers more rationally and Johnson (D-Carrollton) are proposing the
for physicians to take care of their patients. shortage is getting worse. In this already In summary, prior authorizations are prob-
denial means no payment for the physician judiciously. Regular reviews should eliminate elimination of Prior Authorization require-
During this pandemic, many private practices stressed environment of COVID-19, physi- lems for both patients and physicians. Delayed
and a refusal of coverage by the insurer for the services and medications which are unneces- ments for benefits already demanded by the
were not able to survive and had to close; others cians had to spend hours on the phone to get care is unnecessary and should not be allowed.
medication or the procedure for the patient. sarily subjected to Prior Authorization. Time State of Texas such as mammography, prostate
had to furlough or lay off support staff. Prior proper care for their patients. On average, Most of the time, the decisions involved with
Prior Authorization is a system invented by required might be shortened considerably by cancer screenings and diabetes supplies.
authorization was a nightmare even before practices complete 33 prior authorizations per the prior authorization process are made by
health insurers that requires physicians to ob- using online tools and algorithms for rapid These legislators, both Federal and State, are
COVID-19 and its impact during the pan- physician per week. Physicians and their staff someone who is not familiar with the patient
tain advance approval for prescription medica- turnaround. Transparency in communication to be commended. Their efforts are a good
demic is intolerable for patients and physicians. spend an average of almost two days (14.4 or by someone who is not in the same specialty.
tions and medical procedures from a health between insurers and providers must be im- start though they not nearly enough. Reform-
Physicians continue to describe the prior hours) each week completing prior authoriza- Unfortunately, apart from patient care delays,
care plan before delivery to the patient. A re- proved, possibly by creating an NIH panel not ing the Prior Authorization process is a formi-
authorization process as an extremely frustrat- tions. 36% of physicians nationally and 48% prior authorizations also increase the cost for
fusal by the insurance company does not deny affiliated with insurers in order to avoid a con- dable task; insurers have absolutely no
ing process that hurts their patients. For exam- of physicians in Texas report that they have to the patients and the health care system.
or reject the medication or service; it simply flict of interest. Continuity of patient care incentive to change their current practices.
ple, in my wound care practice, a delay in prior hire staff just to work on prior authorizations.
states that the insurer will not pay. Health Care should be deemed critical, with special atten- Obfuscation, confusion, and bureaucratic in-
authorization could potentially delay healing. Most patients do not realize how much Jayesh Shah, MD, a wound care
Plans contend that Prior Authorization pro- tion regarding the avoidance of interruptions efficiency have always been insurance com-
There is evidence that once a diabetic patient work their physicians put in behind the scenes specialist certified in Internal Medi-
grams are important for controlling costs and and delays. Finally, the adoption of electronic pany tactics when dealing with physicians. It
has an amputation, they have a mortality of to authorize care with insurance companies. cine and Undersea and Hyperbaric
avoiding unnecessary or non-standard care. Prior Authorization transactions based on ex- seems that the object of the insurance com-
68% within five years. It is higher than the Most physicians get multiple denials before fi- Medicine, is a member of the Board of Trustees
Cost Control began in the 1950s with con- isting national standards could significantly pany is to collect premiums and to not pay
mortality of breast cancer, prostate cancer, and nally getting approval. 85% of Texas physi- of the Texas Medical Association.
cerns about increasing hospitalizations. improve the process for everyone involved. claims. The Prior Authorization system is
lymphoma combined. cians report delayed access to care and 81%
Medicare and Medicaid legislation in the U.S. Representatives Suzan DelBene (D- onerous, time consuming and very expensive Resources
Over the last five years, the vast majority of report interrupted continuity of care as an
1960s necessitated the creation of Utilization WA), Mike Kelly (R-PA), Roger Marshall MD to physicians. It is potentially devastating to
Texas physicians (87%) and AMA physicians outcome associated with these prior authori- Doctors say that delays are hurting patient out-
Review committees. These usually evaluated (R-KS), and Ami Bera MD (D-CA) intro- patients. It does make more money for insur-
(88%) say that they have seen an increased zations. 78% of physicians report that patients comes https://www.medicaleconomics.com/
the appropriateness of hospitalizations as well duced HR 3107 in June, 2019. This bill would ers. The efforts of the AMA and the TMA and
burden as a result of the PA process, and 69% abandon treatment due to prior authorization view/prior-authorizations-negatively-affect-care
as problematic physician behaviors. Gradually, require Medicare Advantage Plans to stream- the work of the involved legislators are sup-
of Texas physicians describe it as very burden- problems. Even worse, 35% report delayed https://www.ama-assn.org/system/files/2020-
this evolved into a program called Prior Au- line and standardize Prior Authorizations and ported by all independent physicians, and
some. The number of prior authorizations re- care leading to serious adverse events. The 06/prior-authorization-survey-2019.pdf
thorization, a process designed to provide pa- improve transparency in health insurer pro- there must be continued aggressive activity to
quired for prescription medications (85%) AMA survey shows that 16% of physicians re-
tient protection and cost savings. In theory, grams. The bill is called the Improving Seniors’ reform the Prior Authorization system.
and medical services (80%) continues to in- port that a prior authorization led to a pa- 2020 TMA Survey on Prior Authorization -
these concepts were seen as a benefit to con- Access to Timely Care Act, and it now right-
crease, inversely impacting the access to care tient’s hospitalization, which unnecessarily 309767 Prior Auth Data Sheet One-
sumers because the result would be the pre- fully has the bipartisan support of 219 mem- Neal S. Meritz MD is a retired
for patients. increases the cost to the health care system. pager.pdf
vention of unnecessary procedures and the bers of the House of Representatives. In Family Medicine physician and a
With decreasing reimbursement and in- Another problem with the prior authoriza- Shah JB, Sheffield P, Fife, Textbook of
avoidance of expensive brand name medica- December, 2020, this legislation was intro- member of the Bexar County Med-
creasing overhead to obtain prior authoriza- tion process is that there is a wait time for any Chronic Wound Care, Best Publishing 2018.
tions when cheaper generic alternatives exist. duced into the Senate by John Thune (R-SD) ical Society Publications Committee.

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