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Prior authorization

We need a better law

By Sheldon Berkowitz, MD, FAAP

rior authorization reform is long overdue in Minnesota. It has been discussed by physicians and lawmakers for many years, but nothing has changed. In a 2017 national AMA survey on prior authorization, 51% of respondents said that their prior authorization burden had increased substantially over the previous five years. Two companion bills now before the state Legislature—House File 3398, sponsored by Rep. Kelly Morrison, MD, an OB/GYN, and Senate File SF3204, sponsored by Sen. Julie Rosen—could bring some much-needed improvement to the existing law.

For clinicians who have determined a path of treatment—only to face delays or denials of insurance coverage—this new legislation could ease the path to providing better care. It could also empower patients in resolving disputes with insurance carriers over services that should have been included under their plans, but for which they received no approval or coverage.

A personal perspective

Recently, I had the opportunity to testify on behalf of this proposed legislation before the House Health and Human Services Committee. Committee testimony is one way that potential changes are brought forth for a bill. In addition, numerous stakeholders also have a chance to meet with the bill’s authors and recommend changes. For a bill like this, organizations such as the Minnesota Council of Health Plans have had extensive input, resulting in changes such as lengthening the period of time a utilization review organization (URO) would have to respond to a prior authorization request from what the bill’s authors initially proposed. The initial proposal was to have a 36-hour limit on responding for all requests (down from the current law that allows 10 days for a standard determination or 72 hours for expedited requests), but as the bill has progressed, that time has increased to four business days for standard and 48 hours for expedited responses.

​Most doctors view prior authorizations as an attack on their autonomy.

While I understand the desire of insurance carriers to lower and control health care costs and the role of prior authorization in addressing that goal, patients and their families often endure long waits to see if the prior authorization will be approved. That same 2017 AMA survey found that 30% of the time, the wait to get a response to a prior authorization request was at least three days. At our hospital, we have had occasions where inpatients needing to go home with durable medical equipment (DME), such as feeding pumps, have experienced delays in getting approvals. Rather than wait for the prior authorization approval and delay their child’s discharge, families end up having to pay for the pumps out of pocket and hope that, in the end, their insurance company will authorize the equipment and reimburse them. Patients should not have to wait for essential equipment or services.

In addition, I am very aware of the roadblocks that the current prior authorization processes can present to a clinician wanting to provide the best care for his or her patients. There is an unspoken message by insurance companies and pharmacy benefits managers (PBMs—another type of URO), that clinicians are not able to decide which tests or medications a patient needs and that these UROs are better able to decide this. A 2019 Medical Economics article, “The impact of prior authorizations” (https://tinyurl.com/mp-prior-authorization), stated that “  Most doctors view prior authorizations as an attack on their autonomy, their years of training, and their ability to care for their patients. Plus, there’s the time wasted and revenue lost due to haggling with payers over approval for drugs and tests.”

At the Committee hearing, a representative of the Minnesota Council of Health Plans actually stated that health plans may know more than the clinician about what medications or tests are best for a patient. The Blue Cross Blue Shield of Minnesota website states the following about what their decisions are based on: “Blue Cross makes prior authorization decisions using the Blue Cross Medical Policy. This policy includes evidence-based guidelines from the World Health Organization. Registered doctors and nurses regularly review these guidelines.” (See https://tinyurl.com/mp-prior-authorization2.)

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Current practices

Prior authorization affects patients and clinicians in obtaining approval for procedures, inpatient admissions, medications, and durable medical equipment. The process of obtaining this authorization is time consuming on the part of clinicians and their office staffs and often seems to be designed to delay or prevent approval in the best interests of the insurers, not the patient. The 2017 AMA Survey found that 14.6 hours per week were spent by physicians and staff completing prior authorization work. I recently heard from a nurse in one of our clinics that she had spent over 13 hours on the phone over the period of a month trying to get one medication approved for a patient. Clinics and hospitals across the state have staff dedicated solely to processing prior authorization requests and appeals. In my hospital, we estimate that we have about 30 full-time equivalents (FTEs) on the front end working on prior authorization and another 10 FTEs on the back end fixing prior authorization issues. The administrative costs of handling these prior authorization matters are enormous.

We have all experienced problems with obtaining prior authorization approval for a medication or DME on a Friday afternoon for a patient awaiting discharge from the hospital, when the insurance company prior authorization department, or another URO such as a pharmacy benefits manager, tells you they are closed over the weekend. At the recent Committee hearing, one legislator asked the same representative of the Minnesota Council of Health Plans who testified that insurance plans may know better what medications or procedures a patient may need than their clinician, why insurance plans can function on a Monday–Friday, 8–5 schedule, if hospitals and doctors function 24/7? The Health Plans representative did not have a good answer for this question. As previously mentioned, the proposed legislation would shorten the time health plans or UROs are allowed to review a prior authorization request to speed approvals (although, as mentioned above, the current version does not go as far as would have been liked).

​We have all experienced problems with obtaining prior authorization approval.

There are also cases where delays in prior authorization for outpatient medications can lead to increased morbidity and possible emergency room visits and hospitalization. At our hospital, we have seen situations where prior authorization for outpatient IVIG administration for patients with immune deficiencies or treatments for patients with hemophilia were delayed, resulting in complications for patients. Any potential savings the prior authorization process purports to provide are immediately lost when a patient finds themselves in an emergency department, the most expensive, least efficient place to receive care.

Other examples

Another problem with current prior authorization processes is that often, URO personnel may be using algorithms that “help” them decide when to approve or deny a request. They may have little to no medical training to make these decisions. One example where the current law can create delays is in our Pediatric Cardiovascular Intensive Care Unit, where we have often received denials and delays in getting a medication called sildenafil approved for our patients. You may know this generic drug by its more common brand name, Viagra, and I wouldn’t be surprised if many of you may have the same response that some URO reviewers have, which is, “why would a pediatric patient need Viagra?” However, in pediatric cardiology or intensive care, this drug is commonly used to treat pulmonary arterial hypertension. The medication helps to reduce the pressure. Having a URO not understand this often delays treatment and discharges from the hospital. Current law requires that a licensed physician in Minnesota make the prior authorization determination. This new law would require that this physician also “have experience treating patients with the illness, injury, or disease for which the health care service has been requested.” Requiring a pediatric cardiologist, intensivist, or neonatologist to review the request would expedite the response and most likely lead to approval.

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Finally, in pediatrics, we have also seen situations where our young patients in the hospital are denied liquid preparations for a medication by a URO and instead told we must prescribe a tablet. While it is common sense to any of us with children or grandchildren that young children often can’t swallow pills, apparently that doesn’t fit into a URO algorithm, especially if the tablet form is less expensive. Having a knowledgeable physician make these decisions will help.

Summing up

Rep. Morrison and Sen. Rosen’s bill to streamline and improve the prior authorization process is a significant step in the right direction. The bill also provides much needed transparency to the prior authorization process by requiring health plans to list annually how many prior authorization requests they received and what the outcome of those requests was. Prior authorization can play a role in helping reduce health care costs, but all too often it delays or compromises patient care while adding administrative costs and burden. We can do better, and this legislation is a great start.

Get involved

Prior authorization affects all physicians and health care providers. Reach out to your state representative or senator to share your thoughts on House File 3398 and Senate File SF3204. Search for names and contact information at www.gis.leg.mn/iMaps/districts/.

To check the status of either bill, visit www.leg.state.mn.us/leg/legis. This webpage also includes a link to sign up for the Legislature’s “MyBills Personalized Bill Tracking” email service, which delivers alerts on specific bills.

Sheldon Berkowitz, MD, FAAP, is a general pediatrician as well as the Medical Director for Case Management, Utilization Management and Clinical Documentation Improvement at Children’s Minnesota. He is also the President-Elect of the Minnesota Chapter of the American Academy of Pediatrics. He has testified at the Minnesota Legislature several times in the last year.