Well being insurers’ use of prior authorization – a medical administration device requiring suppliers to hunt the insurer’s approval earlier than their affected person receives a healthcare merchandise or service – seems to be on the rise. Whereas suppliers and sufferers increase considerations that prior authorization can inhibit affected person care and enhance administrative burdens for clinicians, insurers argue that prior authorization is a vital device to curb prices and inappropriate service utilization.
To study extra about how policymakers are responding to those considerations, we checked out 4 states’ prior authorization insurance policies for the industrial market: Arkansas, Illinois, Texas, and Washington. Via qualitative interviews, surveys, and coverage evaluation, we examined a spread of state-level prior authorization reforms, and supply an evaluation of how they’re affecting sufferers, suppliers, and insurers.
We discover that there isn’t any single “silver bullet” reform of prior authorization insurance policies or practices that may ease supplier burden and enhance affected person entry with out additionally growing insurers’ prices, however a number of reforms mentioned on this research present potential, together with:
- Requiring higher transparency of companies topic to prior authorization, medical evaluate requirements, and the explanations for denying prior authorization requests;
- Setting most time intervals for insurers to answer prior authorization requests;
- Standardizing the shape and methodology for exchanging prior authorization requests, choices, and associated data; and
- Establishing expectations for peer-to-peer evaluate of prior authorization requests and using accepted and clear medical evaluate requirements.
Finally, the impact of state-level prior authorization reforms depends upon their design, implementation, advert enforcement, and needs to be coupled with federal motion to increase reforms to employer plans that fall outdoors state regulation.
Learn the complete report here.
Funding for this analysis and report was offered by the Robert Wood Johnson Foundation. Further publications by CHIR researchers could be discovered here. CHIR consists of a group of nationally acknowledged consultants on personal medical health insurance and well being reform. For extra on our work, please see our website, blog, and comply with @GtownCHIR on X (previously Twitter).
