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The American Medical Association wants the National Association of Insurance Commissioners to start a working group that would address physicians' concerns about health plan prior authorization programs.
Dr. John Whyte, the AMA's chief executive officer, recently wrote to Grace Arnold, the chair of the NAIC's Regulatory Framework Task Force, to ask her to create the working group.
A working group could look at what states have already tried and identify a list of "best practices" for ensuring that "prior authorization is not preventing access to medically necessary care," Whyte wrote in the letter.
"Additionally," Whyte wrote, "a working group could consider model prior authorization regulation."
Whyte was reacting to recent Regulator Framework Task Force work on a "white paper," or background paper, on prior authorization programs.
The Regulatory Framework Task Force talked about the draft paper during a recent teleconference meeting, and it plans to talk more about the draft Dec. 10, during an in-person session at the NAIC's upcoming fall national meeting in Hollywood, Florida.
Arnold, the task force chair, is the commissioner in charge of the Minnesota Department of Commerce, the state agency that regulates insurance in her state.
Prior authorization: Health insurers and employers' self-insured health plans use prior authorization programs to ask doctors to explain decisions to recommend expensive, unusual or potentially unnecessary forms of care before the care is provided.
Physicians argue that they often end up having to waste time justifying standard, clearly necessary care to physicians outside their specialty or others who know little about the kind of care being recommended.
Health insurers, health plans and health plan administrators contend that prior authorization programs can be a valuable tool for protecting patients and payers from low-value care.
Dr. Mehmet Oz, the new administrator of the Centers for Medicare and Medicaid Services, has suggested that payers could improve prior authorization programs by joining together and applying prior authorization efforts to one standard set of procedures.
What it means: For employers, new, well-crafted prior authorization rules could mean fewer coverage disputes and better care for health plan participants.
Poorly designed rules could lead to patients suffering health problems as a result of getting poorly managed care.
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