Colorado Medical Society

Medical community unites over patient prior authorization

Sunday, January 01, 2012 12:18 PM

Task force to address physician concerns

Susan Burke, Director, Communications

At the start of the 2012 Legislative session, the Colorado Medical Society Council on Legislation (COL) convened to discuss the prior authorization bill sponsored by Senate Majority Leader, John Morse (D-Colorado Springs). Proposed Senate Bill 12-065 requires prescribing providers and health plan benefit plans to use a uniform prior authorization form for purposes of submitting and receiving requests for prior coverage of a prescription drug. If the health plan benefit plan fails to use or accept the prior authorization form or fails to respond to a request within two business days, the request is deemed granted. An approved prior authorization form would be valid for 12 months after the date of approval.

Concurrent to the introduction of the bill, and at the request of the COL, CMS made the decision to assemble a voluntary work group of practicing physicians to engage with the health plan medical directors to review the bill, expand the scope beyond prescription prior authorization and propose solutions. According to CMS President F. Brent Keeler, MD, “The process of engaging with the resources in our medical and legislative communities is working. While we reserve the right to take our case to the legislature, a voluntary engagement with the health plan medical directors will get more issues impacting physicians on the table, involve a thoughtful, thorough discussion of the problems and give us an opportunity for well-reasoned, meaningful solutions.”

The Colorado Association of Health Plans (CAHP) comprised of Aetna, Anthem Blue Cross/Blue Shield, CIGNA, Colorado Access, Colorado Choice Health Plans, Denver Health, Humana, Kaiser Permanente, Rocky Mountain Health Plans and UnitedHealthCare convened with the Colorado Medical Society and Senator John Morse (D-Colorado Springs) to begin addressing the issues and expedite solutions.

“We are excited that the Colorado Medical Society will work with us to convene a task force with members of the Colorado Association of Health Plans to address physician concerns with prior authorization procedures mandated by health plans for certain medical services, procedures, devices, medications, supplies, and equipment,” says Ben Price, Colorado Association of Health Plans executive director.

A recent poll of CMS members indicated that the majority of physicians found the current pre-authorization policies too limiting and impeded their ability to deliver prompt and individualized medical attention to patients. Many members view prior authorization as having a negative impact on patient care. Clearly, physicians want a simpler, standardized approach for payers.

“We are committed to determining the scope of the issue and to develop solutions that are in the best interest of the patients we both serve, the physicians, as well as the businesses that pay the bills,” adds Price.

The task force will take a phased approach to addressing prior authorization issues, beginning with prescription drugs, and in subsequent phases, addressing medical services, procedures, devices, medications, and potentially supplies and equipment. Additionally, the task force will address standardization among health plans to reduce redundancies and “hassles” for the physicians, a clear priority for physicians according to CMS surveys. Electronic submissions will be discussed and evaluated as well.

Over the next couple of months, CMS and CAHP will remain committed to working together to implement agreed upon solutions to prior authorization. Sen. Morse, who will attend the first task force meeting, has agreed to stay involved in this highly collaborative process. “We could not be more pleased that a pro-patient advocate like Senator Morse will be monitoring the process and the progress of the meetings. It’s all coming together,” says Keeler.

Progress updates and opportunities for physicians to engage in the process will be communicated electronically through the website in the award-winning magazine, Colorado Medicine.