Prior authorization is a case management tool used by third-party payers to control costs and help assure the use of safe and effective tests and treatments. It can be used to permit or limit access to diagnostic tests, procedures, provider visits, or medications. When a provider orders a service covered by the payer’s prior authorization policy, a request for authorization must be completed and submitted to the payer for review. Denial of an authorization request can be appealed, but if the request is ultimately denied, the provider and patient must find an alternative service, pay for the service out of pocket, or decide to go without the service.
At its best, prior authorization helps protect patients from unnecessary, ineffective, or unsafe medical services; at its worst, the process becomes a significant barrier for providers and patients in obtaining the care they believe to be best. Additionally, prior authorization as currently practiced is extraordinarily inefficient: most request forms must still be completed in hard-copy format, then scanned or faxed to the payer; there frequently is a unique form for each test, procedure, service, or medication requested; response times from payers can be so lengthy that many providers and patients become discouraged and fail to follow the process through to the end; many requests are initially denied; and the amount of time (and therefore, cost) invested by the provider and his/her staff can be substantial.
SPPAN does not advocate for the elimination of prior authorization, as it can still produce substantial benefits. We do, however, advocate for substantial improvements in efficiency and transparency, as the current situation’s inefficiency and opacity benefit only the payers. Policies that streamline the process have been adopted by some states, and serve as a model for proactive efforts to ameliorate this area of concern.
The current process for prior authorization is extremely burdensome for both patients and providers. SPPAN advocates for four key features in a reformed prior authorization process. These include use of a single form (no more than 2 pages), available for both access and submission electronically, integration with health records, and an automatic approval after no response within 48 hours.
The current process for prior authorization is extremely burdensome for both patients and providers.