The
Massachusetts Medical Society acknowledges that the cost of care is
rising rapidly and the current rate of health care inflation may
not be sustainable. The Society very much wants to work with
the health care community to address this critical issue and the
implementation of cost-effective evidence-based guidelines to
optimize resource utilization.
Many issues
in the complex world of medicine require a genuine partnership
among stakeholders to ensure the community reaches the mutual goal
of expanded access to affordable quality medical care. However, in
light of increasing health care costs, many health plans are
exploring reinstitution of some elements of managed care that were
prominent in the 1980s and had fallen on disfavor in recent
years.
Health plans
have recently implemented unduly, burdensome requirements for
pre-certification/pre-authorization processes with potentially
serious effects on the management of physician practices,
physicians' relationships with patients, and physician morale. The
Society cannot support pre-certification programs that interfere
with the physician-patient relationship.
Physicians
want their patients to be informed, and welcome their partnership
in making the best health care decisions. These circumstances
presented an appropriate opportunity for the Massachusetts Medical
Society, through itsTask Force on Medical Cost Control, to develop
and promulgate Principles for the Use of Prior Authorization
Programs.
These principles for the use of prior authorization programs
should apply whether the program is administered by a health plan,
third party vendor, or provider organization.
1. Prior authorization programs should be implemented only upon
a showing of substantial variation in the targeted practice and
good evidence of overutilization among those providers the proposed
prior authorization program would affect. Such data should be
shared with the physician community well before any action is taken
regarding new prior authorization programs in order to allow for
appropriate improvement.
a. Prior authorization requirements should never apply in a
medical emergency, or when a patient could be harmed by the delay
caused by such programs. If care is required on an urgent basis,
prior authorization requirements should be suspended.
b. The party running a prior authorization program should
actively seek input from practicing physicians in development and
maintenance of the program.
2. All prior authorization programs should be entirely
transparent to patients and physicians. This includes the provision
of:
a. A complete list of all procedures subject to any prior
authorization, including all relevant codes for providers.
b. Comprehensive clinical criteria and algorithms, as updated
based on current medical literature.
3. Prior authorization programs should be operated in a manner
that avoids administrative burdens for physicians and their office
staff and incremental costs to physicians, other providers, and
patients. Data should be reviewed frequently, and physicians who
are meeting criteria should be excluded from the program. Proper
notice of any change in prior authorization process or criteria
should be communicated in a timely fashion.
a. Data collected for prior authorization programs should
include a minimum number of necessary data elements.
b. Providers should be allowed to transmit required data in a
number of different ways, including telephonic, fax, U.S. Postal
Service, and electronic, in a Health Insurance Portability and
Accountability Act (HIPAA) compliant manner.
c. Prior authorization programs should have adequate capacity
such that there are no busy signals or delays in transmitting
data.
d. Providers should receive immediate proof of submission of
prior authorization data.
e. Turnaround time for prior authorization should be less than
one business day for non-urgent cases.
f. Appeals rights for patients, families, and providers should
be clearly spelled out, and appeals should be readily
accessible.
g. Appeals should require the minimum incremental
information.
h. Patients, families, or providers should have the right to
present appeals information in person at a time and place that is
reasonably convenient.
i. Providers should be paid for incremental work effort of prior
authorization programs.
j. Providers should receive timely, clear, and actionable
reporting on their performance in a prior authorization
program.
k. Providers who consistently meet clinical criteria should be
exempted from all elements of prior authorization programs.
l. Documentation of a denial should be sent to the clinician to
include the date and time of the decision, reason for denial and
physician making the denial decision.
4. Prior authorization programs should be conducted using
up-to-date clinical criteria and appropriate clinical experts.
a. All clinical coverage criteria should be reviewed and updated
regularly with evidence-based protocols.
b. Any denials should be issued by a licensed, board certified,
actively practicing physician who regularly treats patients in a
clinical setting and who would typically manage the medical
condition under review. Such a physician should be available
whenever a preauthorization is required.
c. Those conducting prior authorization programs should maintain
a roster of patients who have been issued denials, and plans should
track their subsequent care for the problem for which imaging was
requested.
Originally adopted by
the MMS House of Delegates, December 3, 2005
Updated by the MMS Board of Trustees, February 7, 2007
