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Prior authorizations, or PAs, are an integral part of the healthcare system, designed to manage costs and ensure the medical necessity of treatments, procedures and medications.
However, the confirmation process may delay treatment, including urgent care situations that are not emergencies.
Prior Authorization and Medical Emergencies
First, remember this: Prior authorization is never required during medical emergencies.
No Surprises Act regulations confirm this.
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The term "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in the Emergency Medical Treatment & Labor Act (EMTALA), including:
(1) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
(2) serious impairment to bodily functions, or
(3) serious dysfunction of any bodily organ or part.
The current regulatory standard for prior authorization on urgent care claims is "as soon as possible," but no later than 72 hours.
Other Situations
The U.S. Department of Labor and advocacy groups such as the American Medical Association hope to shorten the PA timelines now allowed for situations that are not medical emergencies.These changes aim to address patient advocate concerns and ensure that urgent care decisions are made more efficiently without creating undue complexity for providers or payers.
The Problem with the Current Timeline
In its current form, the regulations mandate prior authorization decisions be made as soon as possible, but no later than 72 hours, to balance thorough review with timely decision-making.
However, testimony from patient advocates and medical professionals shows that claim processing has significant shortcomings:
◆ Patient harm due to delays: For individuals requiring urgent care, even a delay of a few hours can lead to the progression of diseases, worsening pain or irreversible medical outcomes. Patient advocates report that the current timeline fails to reflect the realities of medical care, particularly in cases where immediate treatment is required.
◆ Provider challenges: Medical professionals often struggle with receiving timely responses for urgent care requests, forcing them to delay treatment or proceed without authorization, potentially risking reimbursement disputes.
◆ Administrative burdens: Reducing the 72-hour limit may appear straightforward, but creating exceptions or tiered response categories could introduce new complexities and confusion, complicating the process further for all stakeholders.
Medical providers are themselves subject to emergency regulations.
So, hopefully, in any update of the prior authorization provisions in the ERISA claim regulations, the Labor Department will clearly distinguish the definitions of medical conditions that are "urgent" (where prior authorization is permitted) from those that are "emergency" (where prior authorization is not allowed).
It is important to note that during the ERISA Advisory Council's 2024 discussions, testimony often blurred the line between "urgent" and "emergency" care.
The final report did not consistently clarify this difference, leading to concerns that stakeholders may incorrectly assume prior authorization applies in true emergencies.
As emphasized in the sidebar above, that is never the case.
Providers are legally obligated to treat emergencies immediately, without prior authorization and failure to draw this regulatory line risks misapplication in policy or use.
Proposed Reforms: A Focused Approach
The AMA and other advocacy groups have called for revisions to the current regulations, emphasizing the importance of reducing the response time for prior authorizations of urgent care.
A well-balanced reform must address the needs of patients while maintaining efficiency for providers and payers.
Key recommendations include:
1. Shorten the decision timeline:
Reducing the maximum response time for urgent care claims to 24 to 48 hours would align the process with the urgency of medical situations.
2. Standardize the definition of urgent care:
A clear and uniform definition of what qualifies as "urgent care" is critical.
Currently, payers may interpret urgency differently, leading to inconsistent application of the 72-hour rule.
A standardized definition can streamline decision-making and reduce disputes over what constitutes an urgent claim.
3. Introduce automated systems:
Technology can play a significant role in accelerating prior authorization decisions.
Automation and artificial intelligence tools can assess urgent care claims more efficiently, ensuring faster turnaround times without sacrificing accuracy.
4. Monitor compliance and remedies:
The DOL should consider what remedies are appropriate for failure to meet required response times.
Establishing accountability mechanisms, such as financial penalties or expedited appeals for delayed claims, can ensure adherence to regulations.
The 2024 ERISA Advisory Council echoed many of these recommendations in its newly released report, Group Health Plan Claims and Appeals.
The council urged the Labor Department to "update existing regulations relating to urgent care claims to speed the processing of such claims" and to "consider imposing consequences in situations where regulatory guidelines are not followed." These conclusions directly support efforts to improve the timeliness and effectiveness of urgent care prior authorizations.
Avoiding the Pitfalls of Added Complexity
Should the department decide to reduce the 72-hour timeframe, reforms must avoid introducing unnecessary complexity.
Creating multiple tiers of urgency or allowing numerous exceptions could increase confusion for both providers and payers.
Instead, reforms should focus on:
◆ Clarity in implementation: Ensure that any changes are straightforward, with clear definitions, timelines and processes for urgent care claims.
◆ Minimizing administration: Avoid requiring excessive documentation or redundant approvals.
◆ Provider incentives: Encourage use of "gold carding," where plans identify and exempt high-performing providers from prior authorization requirements.
The Role of Employers and Plan Sponsors
Employers and plan sponsors play a pivotal role in advocating for reforms to PA processes.
By negotiating for more efficient procedures with payers, they can help ensure that employees receive timely and appropriate care.
Beyond this, employers can take proactive steps to support their workforce, such as educating employees and providing access to advocacy services that offer expert assistance in navigating our complex health care system.
Additionally, employers can incorporate performance metrics that monitor payer compliance with PA timelines, safeguarding employees from unnecessary delays and reinforcing accountability within the system.
These efforts would demonstrate a commitment to employee well-being.
A Call for Collaborative Change
Avoiding unnecessary delays in prior authorization will improve treatment outcomes.
Standardizing definitions and leveraging technology are actionable steps that can improve the system without introducing undue complexity.
Christine M. Cooper is the CEO of aequum LLC, a patient advocacy firm.
Jack M. Towarnicky, CEBS, is an ERISA and employee benefits compliance and planning attorney with Koehler Fitzgerald, a member of the aequum< LLC patient advocacy team and a member of the federal ERISA Advisory Council.
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