18 Jan AMA’s model bill “Ensuring Transparency in Prior Authorization Act” engages with AHIP and BCBS for action
The AMA’s model bill, the “Ensuring Transparency in Prior Authorization Act,” is designed to make the PA process timelier and less opaque. The CrossBridge solution helps connect rheumatologists and health plans to alleviate the administrative burden. It helps physicians select a treatment option to obtain electronic preauthorization at the time of prescription so that patients can begin treatment without delay.
The purpose for the legislation is spelled out clearly, and it cites a need to guard against PA programs that attempt to place “cost savings ahead of optimal patient care.”
The model bill would require that the health plan or “utilization review entity” post online their current PA requirements and restrictions, including clinical criteria.
Statistics on PA approvals and denials for medications, procedures or diagnostic tests would have to be posted for each medical specialty. Also, reasons for denial and statistics on what procedures most often trigger the PA process would have to be made available.
Under the AMA model bill, PA determinations would have to be made within two working days for non-urgent care and within one business day for urgent care. No PA requirements would be allowed for emergency care.
Also, if—after emergency care is delivered—immediate post-evaluation or post-stabilization services are needed, a determination must be made within 60 minutes of the request. If utilization reviewers don’t make a determination within 60 minutes, “such services shall be deemed approved,” the model bill states.
Other provisions include a ban on retroactively denying authorization or payment within 45 days after receiving approval. The bill also requires insurers to accept and respond to standard electronic PA transactions for prescription medications and makes clear that faxes, proprietary payer portals and electronic forms shall not be considered electronic transmission.
The AMA Advocacy Resource Center has developed a chart that summarizes individual state laws for PA timeliness, transparency and electronic transmission.
Earlier this year, the AMA joined with other stakeholders—including the insurance industry trade group America’s Health Insurance Plans and the Blue Cross Blue Shield Association—to issue a consensus statement on prior authorization that encourages “transparency and easy accessibility of prior authorization requirements, criteria, rationale and program changes.”