At ViVE 2024, Panelists Share Prior Authorization Progress and Frustration in Payer Insights Program

At the Payer Insights sessions on Day 1 of ViVE 2024, a panel on prior authorization offered compelling insights from speakers who shared the positive developments in this area after years of mounting frustration. Stakeholders have been motivated to enact changes at every level to improve the time it takes for health insurers to approve coverage queries from physicians.

But some of these developments also pose challenges as payers, providers, and policymakers figure out how policy developments and technology will fit together in practice. The main issues to emerge from the discussion were what will reform look like when the Centers for Medicare and Medicaid Services (CMS) Final Rule goes into effect, and how the final rule will work with policies enacted at the state level. Additionally, panelists discussed how APIs could speed up the prior authorization process further and with added context and transparency for payers’ decisions.

Currently, the prior authorization landscape in the U.S. is a mishmash of programs of varying effectiveness. At the optimum level, payers respond to physician queries within minutes. But physician frustration with delayed responses or rejections without clarity, which lead to more work on their part to resolve and can jeopardize patient health, has spurred a wide variety of responses. Some states have enacted the practice of “gold carding” where health plans allow physicians who maintain a 90% approval rate for specific services over a six-month period to waive prior authorization rules. Insurance companies have removed certain medical services from prior authorization, such as cataract surgery, physical therapy, and some genetic tests and prosthetics, among other things. There are also various third-party health tech tools to speed up prior authorization, with varying effectiveness.

MedCity News Senior Reporter Katie Adams moderated the panel discussion, which included:

• David Dobbs, Vice President, Chief Data Officer, Hawaii Medical Services Administration
• Timothy Law, Chief Medical Officer and Vice President Integrative Care Delivery, Highmark Health
• Ginny Whitman, Senior Manager, Public Policy, Alliance of Community Health Plans

Whitman welcomed the final rule, particularly its acknowledgment that CMS recognizes that artificial intelligence (AI) has been used for years to assist health plans in making coverage determinations for prior authorizations. But she also shared why she thinks it will be a “game changer.”

“Most importantly, I think is these prior authorization Application Programming Interface (APIs) regulations that just were finalized within the last couple of weeks. The industry is anxiously anticipating these and I think this is really going to make a difference coming into 2027 when they go into effect. The other really important person that’s participating in this process is the provider. Health plans need certain information from providers about patients and without that they cannot adequately make a determination. So these APIs are going to be a big game changer. But another key point that these rules are going to offer is transparency into metrics around prior authorization. Not only will providers have an easier time, patients will be able to see metrics about their health plans and the various determinations that are being approved, what was approved after an appeal, in 2027. Big changes are happening in this space.”

Law noted how Highmark’s integrated care model informs how it works with providers.

“We are in a unique situation where our providers are very much part of our system. They sit on our medical policy team, they give us feedback on what is and isn’t working. We make changes literally on a daily basis based on that kind of [feedback]. We can kind of customize it for each particular provider that way. It needs to be transparent, needs to be open.”

In defense of the need for prior authorizations, Whitman shared an anecdote about what she described as “a cultural phenomenon” where one health plan member from the Alliance of Community Health Plans approved a provider’s requests for inductions prior to 36 weeks ahead of the baby’s projected delivery.

A decision was made to stop paying for any induction before 36 weeks and, relatively quickly, inductions earlier than 36 weeks were no longer being scheduled because they were no longer being paid for.

“Patients were having significantly better outcomes. You need to have that provider in the room helping you make those decisions when you’re setting up your policies along with your protocols for prior authorizations,” Whitman said.

Asked about legislation by one state to sharply reduce prior authorization, Law expressed his dismay.

“That’s an acceptance of waste that is unethical,” Law said. “Can you imagine 20% waste in anything you do on a daily basis? Studies have been done on Medicare fee-for-service about the amount of authorizations that are wasted, that lead to not only bad care and unnecessary care downstream.”

Whitman predicted that in their desire to give providers more freedom from the limitations of prior authorization or set their own terms for prior authorization practices they will ultimately clash with CMS.

“I hesitate to say that states are ahead of the curve and implementing regulations and legislation that are going to be valuable,” Whitman said. “It’s possible that they’re out there, but what is more likely to happen is they’re going to have conflicting regulations with what happens at the federal level. That’s ultimately just going to force providers and health plans to have to navigate two sets of duplicative or confusing regulations.”

Photo: Stephanie Baum, MedCity News