PAMED Member in D.C. to Urge More Efficient Approach to Prior Authorization

Last Updated: May 23, 2018

Prior authorization reform was a point of emphasis for Pennsylvania Medical Society (PAMED) Past President James Goodyear, MD, FACS, when he spoke before the National Committee on Vital Health Statistics (NCVHS) in Washington, D.C. on May 17, 2018.

goodyear-CIO-forumDr. Goodyear participated in NCVHS’ Chief Information Officers’ forum during which stakeholders offered input into health care administrative standards and operating rules. He noted that authorization requests are where his practice and physician practices on a national level would like to see more innovation.

Many prior authorization requests, particularly follow-up, still occur via telephone or fax, said Dr. Goodyear. This results in administrative burden for practices both large and small. “In an age where we can attach consolidated clinical document architecture (C-CDA) to a direct secure message for a referral to another provider, how can we integrate this with our payers?” he asked in his written testimony.

He asked the committee to urge health plans to:

  • Reduce their prior authorization requirements and limit application to true outliers
  • Consider using existing infrastructure of the practice management system/electronic health record to enable the prior authorization request, encouraging interoperability, transparency, and the ability to manage data in one central location.

Dr. Goodyear also addressed additional areas in which electronic transactions can be improved to increase efficiency and reduce practice burden. These include:

  • Claims denials—In many cases, the Claims Adjustment Reason Codes (CARC) and Remittance Advance Remark Codes (RARC) do not always match the explanation of adjustments or match the reason for denial.
  • Eligibility verification—The eligibility function is helpful to verify if a patient is enrolled in a plan, and in some cases, whether a patient may participate in any other plans. However, data on deductibles, coinsurance, and copayment is not drilled down far enough to be valuable. Dr. Goodyear noted that deductible amounts are often not accurately reflected during eligibility verification.
  • Coordination of benefits (COB)—More often than not, there is not enough data to facilitate COB. If a health plan could share a patient identification number of the additional plan or plans, it could alleviate some of the guesswork in the billing department.

Read Dr. Goodyear’s written testimony here. To learn more about PAMED’s advocacy on prior authorization reform, visit www.pamedsoc.org/priorauth.

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