A bill strongly supported by CMS that would streamline the overall process of prior authorization was voted out of Senate committee April 11, and now heads to the full Senate for approval. House Bill 19-1211 would promote safe, timely and affordable access to evidence-based care for patients; enhance efficiency; increase transparency; and reduce the variations among payers and utilization management organizations.

Thanks to the practice executives who testified in support of the bill: Brenda Hulbert, MBA, RNBC, AACC, FACMPE, CEO of South Denver Cardiology Associates; Eric Spear, MBAHA, FACMPE, chief administrative officer of Centeno-Schultz Clinic; and Wendy Spirek, chief strategy officer for Children’s Eye Physicians.

Sponsored by Rep. Yadira Caraveo, MD (D-Thornton), Rep. Dafna Michaelson Jenet (D-Commerce City) and Sen. Angela Williams (D-Denver), the bill requires alignment of clinically based criteria across health plans to reduce the administrative burden on physicians and improve adherence. The bill would ensure that services that have been approved cannot be retrospectively denied, and that an approved prior authorization request remains valid for at least 180 days and continues for the duration of the prescribed course of treatment. Under the bill, a health plan must make a determination of a prior authorization request within five days of obtaining all necessary information for non-urgent care, and within two business days for urgent care.

Additionally, carriers are encouraged to limit the use of prior authorization to those providers whose prescribing or ordering patterns differ significantly from their peers, and to offer those providers who have a history of adherence to the carrier’s requirements at least one alternative to prior authorization. This will help in targeting prior authorization requirements where they are most needed and reduce the administrative burden on high performing physicians.

CMS believes HB19-1211 will reduce the costs to patients in terms of time and potential interruptions in care, and reduce the costs to physicians through increased transparency, timeliness and standardization. Recent surveys of both physicians and practice administrators have shown that prior authorization requests have become more burdensome over the past five years and many physician practices have one full-time employee devoted to the tasks associated with prior authorization.

The bill will be heard by the Senate Health and Human Services Committee.

On a federal level, progress in alleviating prior authorization burdens continues to lag. In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health plans signed a joint consensus statement that outlined five key areas for industry-wide improvements to prior authorization processes and patient-centered care. The shared commitment was signed by two trade organizations representing payers: America’s Health Insurance Plans and the Blue Cross Blue Shield Association. But a survey conducted by the AMA in December 2018 showed that prior authorization still poses significant challenges for both physicians and patients and many of the reforms agreed to in the consensus statement have yet to be widely implemented by health plans.

The AMA spearheaded a letter, signed onto by the Colorado Medical Society and most state and specialty medical societies, urging the Centers for Medicare and Medicaid Services to include language about prior authorization in its 2020 Call Letter to Medicare Advantage plans. The letter requested that the federal CMS guidance advise plans that they must carefully consider the care delays associated with prior authorization and the resulting impact on beneficiaries.

Find more information about what the AMA is doing to push for prior authorization reform on the federal level at https://fixpriorauth.org.


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