Physician groups outline 5 ways CMS can lift prior authorization burden

U.S. physicians are calling on the federal government to take a broader approach in reducing the administrative burdens of prior authorization.

In a letter to CMS sent Sept. 20, the American Medical Association and 104 other medical societies said they want CMS to address the issue by incorporating five consensus principles into its policies regarding prior authorization programs and processes.

The principles — created by national provider associations and insurer trade organizations — are listed in the letter as:

  • Selective application of prior authorization 
  • Review/adjustment of prior authorization lists to remove services/drugs that represent low-value prior authorization
  • Transparency of prior authorization requirements and their clinical basis to patients and physicians
  • Protections of patient continuity of care
  • Automation to improve prior authorization and process efficiency

The letter notes the amount of time physician practices report spending to complete prior authorizations as well as the potential for prior authorization to lead to a serious adverse event for patients.

But the AMA and other medical societies said CMS may be focusing only on the technological aspects of prior authorization, such as automation, in implementing reforms to address the issue.

"Automation is important, but it reflects only one of five major reforms we believe are needed to address the significant problems caused by PA," the groups wrote. "While we understand there may be a role for PA, we believe it must be right-sized and used judiciously. We strongly urge CMS to implement a comprehensive strategy to reduce the harms and burdens of PA by facilitating payer adoption of" the consensus principles.

Read the full letter here.


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