Prior authorization a ‘major contributor’ to radiologists’ mounting administrative burdens, ACR tells Congress
Prior authorization is a “major contributor” to physicians’ mounting administrative burdens, the American College of Radiology warned Congress recently.
ACR’s comments came in response to a recent Senate Committee on the Budget hearing, titled “Reducing Paperwork, Cutting Costs: Alleviating Administrative Burdens in Healthcare.” Amid provider shortages and imaging backlogs, lawmakers are seeking ways to ease the stress endured by physicians.
“The ACR has long supported congressional and regulatory efforts to reduce physician administrative burden across all payment systems,” the college said in written testimony. “Prior authorization, which is frequently required by health plans prior to a patient receiving services such as advanced imaging recommended by their physician, is a major contributor to this burden.”
A March survey of hospitals and other facilities from Premier Inc. found that nearly 53% of Medicare Advantage claim denials were eventually overturned, ACR noted. Administrative costs to fight these denials average nearly $48 per claim, the survey found. Inserting this unnecessary roadblock has allowed health insurers to shift costs to radiologists and other physicians, who are forced to waste time filling out paperwork rather than caring for patients.
“Additionally, far too often prior authorization decisions are made by nonphysician health plan employees based on a ‘black box’ set of criteria on a delayed timeline that prioritizes health plan profits over patients,” ACR added.
The college presented the shelved appropriate use criteria program—which requires referrers to consult a decision aid before ordering advanced imaging for Medicare beneficiaries—as a “minimally burdensome alternative to prior authorization.” ACR sees myriad benefits from the program, reducing delivery of low value imaging exams, lessening the burden on overworked radiologists, and saving Medicare $700 million annually.
“In order to move forward with AUC implementation, the ACR has proposed significant administrative simplification amending language to the Senate Finance Committee,” the college wrote. “We urge the swift adoption of the revised, updated legislative text to provide CMS with the statutory changes needed to implement the AUC program. These changes will first and foremost improve patient care by decreasing unnecessary utilization and associated copayment costs while providing a utilization management tool far superior and less burdensome than any prior authorization process.”
In prepared remarks, Committee on the Budget leaders echoed ACR’s concerns around insurer utilization management.
“One particular scourge for patients is prior authorization: confusing, cumbersome and inconsistent insurance rules that stop care while providers spend valuable time documenting and justifying the clinical need for a medicine or service,” Chairman and Sen. Sheldon Whitehouse, D-R.I., said in a statement. “In a value-based system, where doctors make their money by reducing costs and keeping patients healthier, there’s no logic to prior authorization.”
To address this, Whitehouse is proposing that Medicare Advantage plans must get approval from CMS before imposing prior authorization on physicians practicing in successful accountable care organizations. His legislation also would task CMS with identifying the worst prior authorization practices in Medicare Advantage and set common standards for these requirements across insurance plans.
Ranking Member Sen. Chuck Grassley, R-Iowa, expressed hope that recently announced actions at CMS will ease PA challenges.
“I support putting more sunshine on prior authorizations. CMS should be aggressively auditing Medicare Advantage prior authorization activities, so that we have a clear understanding [of] how patients, providers and taxpayers are impacted,” Grassley said in his prepared remarks.
You can find both Senators’ testimony and a recording of the May 8 hearing here. ACR also promoted its comments in a news update published Thursday.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.