New Georgetown CHIR Report Examines State Reforms of Prior Authorization

Well being insurers’ use of prior authorization – a medical administration software requiring suppliers to hunt the insurer’s approval earlier than their affected person receives a healthcare merchandise or service – seems to be on the rise. Whereas suppliers and sufferers elevate issues that prior authorization can inhibit affected person care and enhance administrative burdens for clinicians, insurers argue that prior authorization is a vital software to curb prices and inappropriate service utilization.

To study extra about how policymakers are responding to those issues, we checked out 4 states’ prior authorization insurance policies for the industrial market: Arkansas, Illinois, Texas, and Washington. Via qualitative interviews, surveys, and coverage evaluation, we examined a variety of state-level prior authorization reforms, and supply an evaluation of how they’re affecting sufferers, suppliers, and insurers.

We discover that there is no such thing as a single “silver bullet” reform of prior authorization insurance policies or practices that may ease supplier burden and enhance affected person entry with out additionally growing insurers’ prices, however a number of reforms mentioned on this examine present potential, together with:

• Requiring higher transparency of providers topic to prior authorization, medical evaluate requirements, and the explanations for denying prior authorization requests;
• Setting most time durations for insurers to answer prior authorization requests;
•  Standardizing the shape and methodology for exchanging prior authorization requests, choices, and associated info; and
• Establishing expectations for peer-to-peer evaluate of prior authorization requests and the usage of accepted and clear medical evaluate requirements.

In the end, the impact of state-level prior authorization reforms is dependent upon their design, implementation, advert enforcement, and needs to be coupled with federal motion to increase reforms to employer plans that fall outdoors state regulation.

Learn the complete report right here.

Funding for this analysis and report was supplied by the Robert Wooden Johnson Basis. Extra publications by CHIR researchers will be discovered right here. CHIR consists of a crew of nationally acknowledged specialists on personal medical insurance and well being reform. For extra on our work, please see our web site, weblog, and comply with @GtownCHIR on X (previously Twitter).