Prior Authorization Process: Mandates for Health Plans — What Now?

In the CORRelations post, “Prior Authorization Process: Mandates for Health Plans”, Julie Barnes JD discusses the recent CMS Final Rule that supposedly will decrease the burden of prior authorization for physicians. As she stated, this change will only affect Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the Federally Facilitated Exchanges. The AAOS Office of Government Relations has been advocating aggressively for this rule for several years, and I’m thrilled that this was finally approved.

CORRelations readers need to know that this requirement does not extend to the private insurance companies that plague you with prior authorization calls every week. While surgeons often say, “As Medicare goes, so go the private payers,” there is no requirement in this CMS rule to make the big insurance companies follow Medicare Advantage’s lead. So, while your Medicare Advantage prior authorization calls may decrease, you will probably notice no difference in the number of other insurance prior authorization calls.

It will take state-level advocacy to break the bad habits of the private insurance companies. Your state legislator and your state insurance commissioner have far more influence than the federal government in changing the harassing tendencies of these payers.

If you really want to decrease the insurance delays that disrupt the care of patients, engage at the state level. Work with your state orthopaedic society on this — more than likely, it’s already taken up the cause. If you are not a member, join! Those societies are our leverage here. Then, reach out to your state society’s executive director and ask how you can help fight against unnecessary administrative hassles that only delay important patient care.