Fixing prior auth: Give doctors a true peer to talk with—stat

AMA News Wire

Fixing prior auth: Give doctors a true peer to talk with—stat

May 6, 2024

The time-wasting, care-delaying, insurance company cost-control process known as prior authorization has gone from a rarely employed tool to discourage use of extremely pricey interventions to a form of utilization management that comes as naturally to payers as breathing does to the rest of us.

Prior authorization is overused, and existing processes present significant administrative and clinical concerns. That is why fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians.

Prior authorization is a multifaceted problem that needs to be tackled from numerous angles. High on the hit list are the sluggish response times, an overwhelming and increasing volume of requirements, inadequate peer-to-peer reviews and more. As the physician’s powerful ally in health care, the AMA is tackling prior authorization with research, practice tools and reform resources.

In this third installment of an AMA series on fixing prior auth, we take a look at the need to overhaul the so-called peer-to-peer process that insurance companies use to delay and deny prior authorization approvals. This is a process in which an ordering physician discusses the need for a procedure or drug with another physician who works for the payer in order to obtain a prior authorization approval or appeal a previously denied request.

It is likely that nearly every physician in the nation can share a horror story of having a medication they prescribed or procedure they ordered put through the prior authorization process, and then having to plead their case to move forward—only to wind up talking with someone who does not have the knowledge to make the clinical decision being discussed.

It may be that the health professional on the other end is not a physician. Even when they are physicians, these insurer-paid “peers” often come from a completely different specialty or know little to nothing about the disease or treatment in question. For example, an insurer-employed ob-gyn may be asked to approve or deny a prior authorization dealing with neurosurgery.

Austin, Texas, breast oncologist Debra Patt, MD, PhD, knows the frustration painfully too well. She had a patient ultimately die of metastatic breast cancer after a weekslong delay in care due to prior authorization. After an initial prior authorization request for an evidence-based, promising new drug combination was denied, Dr. Patt sought a peer-to-peer consultation, and it was weeks until she got a call back from the insurer’s physician. In the meantime, Dr. Patt prescribed a more standard chemotherapy regimen to no avail.

“It's really challenging. I think that the peer-to-peer review process would have approved the treatment, but the problem was we couldn't get that in a timely fashion,” Dr. Patt told the AMA. “And, as you know, even if you can get it in a timely fashion, frequently it's not someone with the expertise to really make that decision because … maybe they're not an oncologist, so I think those are real challenges for the patients we serve and that frequently delay and deter care.”

AMA Past President Barbara L. McAneny, MD, an oncologist, similarly knows the aggravation of not being able to get a peer on the phone to make a determination.

She had a patient with breast cancer that had spread to the spinal fluid around the brain. Placing a device into the brain so the chemotherapy can be injected directly into that area is the best way to treat the condition.

Dr. McAneny, an AMA member, sent her patient to the neurosurgeon to have the device implanted, but the insurer refused to give the neurosurgeon permission to perform the procedure, calling it “experimental.” The patient’s care was delayed while Dr. McAneny tried to appeal.

“I could not get past the bureaucracy to get another physician to explain that this procedure is A, lifesaving and B, is definitely not an experimental procedure,” Dr. McAneny said in a moving video that is part of a collection of AMA member physicians’ sharing their awful experiences with prior authorization in practice.

Physicians need to be able to quickly connect with a physician who practices in the same specialty as they do. As the experiences of Drs. Patt and McAneny show, getting to someone who understands the patient’s condition and medically appropriate treatments can truly be a matter of life and death.

The AMA House of Delegates in 2021 adopted policy to advocate that:

• Peer-to-peer (P2P) prior authorization determinations must be made and actionable at the end of the P2P discussion notwithstanding mitigating circumstances, which would allow for a determination within 24 hours of that discussion.
• The reviewing P2P physician must have the clinical expertise to treat the medical condition or disease under review and have knowledge of the current, evidence-based clinical guidelines and novel treatments.
• P2P prior authorization reviewers follow evidence-based guidelines consistent with national medical specialty society guidelines where available and applicable.
• Health plans undertake every effort to accommodate the physician’s schedule when requiring P2P prior authorization conversations.

The “Prior Authorization and Utilization Reform Principles” (PDF) that came out of an AMA-convened workgroup with 16 other state and specialty medical societies, national provider associations and patient representatives also address who should be allowed to make such determinations. The document says that a utilization-review entity is essentially practicing medicine when it makes decisions that can prevent access to care that the physician, along with the patient and health care team, has decided is appropriate and medically necessary.

Utilization-management entities should give ordering physicians “direct access, such as a toll-free number,” to another doctor with the same training and practicing the same specialty or subspeciality “for discussion of medical necessity issues,” the document says.

To varying degrees, more than half of the nation’s states have passed laws (PDF) that deal with the qualifications of the person doing the prior authorization review.

Some of the laws, like the one New Jersey lawmakers passed in 2023, clearly set the standard that physicians who review prior authorization requests or denial appeals have a background in the treatment a physician is requesting and the condition being treated. Others, though, are less specific and only state that, for example, the determination must be made by a physician who is licensed in the state.

With the timing of appeal denials being so important, about half of the states have laws that create rules for peer-to-peer appeals processes. Again, the specificity and time tables differ from state to state. For example, in Alabama, if a physician believes a denial deserves immediate appeal, he or she can appeal by phone on an expedited basis—defined by law as within 48 hours. Meanwhile, in Illinois the law simply establishes that denials can be appealed and reviewed by an external independent review.

At the state and federal levels, the AMA continues to advocate for laws consistent with the policy adopted in 2021, including that reviewing physicians have the clinical expertise to treat the medical condition or disease under review and understand current, evidence-based clinical guidelines and novel treatments.

An AMA model bill (PDF) can help physicians get started on advocating change in their own state legislatures. It includes language to establish that only a qualified physician can make an adverse determination on prior authorization.

Patients, doctors and employers can learn more about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.