Tag: Prior Authorization

Federal rules could streamline prior authorization decisions…but not for drugs

Jason Shafrin

A CMS proposed rule would expedite the prior authorization approval process. CMS summarizes key provisions of the rule as follows: Proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. They also include requirements for certain payers to include a specific reason…

Prior authorization: Burden on physicians and recommendations for change

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Prior authorization policies may save money for payers, but they impose significant costs on patients and providers. A JAMA Viewpoint by Anderson, Darden and Jain (2022) examines various approaches for improving prior authorization in Medicare Advantage. In a recent survey of 1004 physicians, 88% reported that the burden associated with prior authorization requirements was high…

The rise of prior authorization

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While many patients and physicians feel that it is increasingly difficult to get insurance to cover new treatments, a JAMA Viewpoint (Resneck 2020) demonstrates this trend numerically.  Prior authorization requirements increased from 8% to approximately 24% of covered drugs on Medicare Part D plans between 2007 and 2019.1 In 4 therapeutic classes (including antidepressants, autoimmune disease…

The problem with prior authorization

Jason Shafrin1 Comment

Prior authorization is a requirement that health plans require physicians to obtain plan approval in order to prescribe a patient a given medication. Prior authorizations may be put in place to insure medications are not used inappropriately or for payers to try to reduce cost. While prior authorization may help save money, delays in the…

Prior authorization and opioid abuse

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An interesting article by Cochran et al. (2017) examines whether health plan prior authorization rules can help prevent opioid abuse.  The authors use Pennsylvania Medicaid data from 2010 to 2012.  The data included both fee-for-service and managed care enrollees. The authors measured opioid abuse based on diagnosis codes for opioid use disorder (304.0, 304.00, 304.01,…

The Start of Rationing in Medicare?

Jason Shafrin2 Comments

Prior authorization is a common tool that managed care organizations use to reduce patient utilization of medical services.  Some physicians believe that prior authorization creates barriers to effective care, but other commentators believe that prior authorizations can be implemented in a more efficient manner.  Either way, prior authorizations are a form of rationing care. Although…

Is Medicare moving towards rationing your medical equipment?

Jason Shafrin1 Comment

Currently, Medicare fee-for-service (FFS) beneficiaries receive significantly more choice than standard commercial plans.  They can choose any provider they wish (who accepts Medicare).  There are no cost-sharing differences between in-network and out-of-network doctors (because there is no ‘in-network’ for Medicare).  Although certain Part D prescription drug plans require prior authorization for specific drugs, few services…