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Prior Authorization Collaborative Project

Prior Authorization: Current State,
Challenges, and Potential Solutions

Considerations for Improving Prior
Authorization in Healthcare

eHI Explains
Prior Authorization

What is prior authorization?
Prior authorization (PA) is a decision by a health insurer or plan that a healthcare service, treatment plan, prescription drug, or medical equipment is medically necessary to the patient’s treatment, and included in their covered benefits. Prior authorization is meant to optimize patient outcomes and protect their safety.

 

Why is prior authorization important?
Prior authorization is an important aspect of patient care because it outlines what a health insurance plan will cover, protecting patients from unexpectedly paying exorbitant fees for medication and medical devices prescribed by their doctor.

 

How could prior authorization negatively impact care?
Prior authorization is not always a quick process. A recent American Medical Association (AMA) survey revealed that 86% of physician respondents feel that the burden associated with prior authorization in their office is either “high or extremely high” and that they and their staff spend an average of 14.9 hours each week to complete the prior authorization workload. 91% of the hospital staff believe that PA has a negative impact on clinical outcomes.

 

Why is prior authorization needed?
Due to the complex nature of medicine, guidelines are not available for most conditions and situations, therefore prior authorization is needed. Participants in the eHI collaborative acknowledge that prior authorization will continue to be used for the foreseeable future as a utilization management tool, and efforts should focus on streamlining and improving the process.

 

What is the Considerations for Improving Prior Authorization document and webinar?
The burdens of prior authorization are felt by everyone in healthcare, including patients, payers, vendors and providers. eHI brought together executives from each stakeholder group to establish a set of recommended practices to help improve the current prior authorization environment and to respond to the widespread challenges and dissatisfaction healthcare professionals have with prior authorization. The Considerations for Improving Prior Authorization in Healthcare document primarily addresses medical services prior authorization. eHI rolled out the Considerations document with a press release and webinar. Our eHealth Resource Center contains a recording of the webinar and presentation slides.

 

Who was involved in the eHI collaborative process?
The list of individuals who participated is long and inclusive. Organizations involved included: American Academy of Family Physicians (AAFP), America’s Health Insurance Plans (AHIP), American College of Cardiology (ACC), American College of Radiology (ACR), American Heart Association (AHA), American Medical Association (AMA), Automated Clinical Guidelines, CAQH, Change Healthcare, Delaware Health Information Network (DHIN), DirectTrust, EnableCare LLC, eHealth Initiative, eviCore Healthcare, GE Healthcare, Haven Health Solutions, Highmark, Health Level Seven International (HL7), Kaiser Permanente, Marshfield Clinic, Medical Society of Delaware, Medical Group Management Association (MGMA), National Alliance of Healthcare Purchaser Coalitions, Office of the National Coordinator for Health Information Technology (ONC), Point of Care Partners, Stratametrics LLC, UnitedHealthcare, Virence Health, Workgroup for Electronic Data Interchange (WEDI).

 

Why did eHI decide to address this issue?
eHI first identified this issue during the eHI Executive Summit in February 2018. eHI has a long history of convening executives concerned with technology and information. Prior authorization involves numerous exchanges of information, many of these processes could be streamlined through the use of electronic health records.