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Understanding prior authorization and the bill that seeks to change it

Recently, 370 patient, physician and healthcare professional organizations sent a letter to Congress urging the passage of H.R. 3107, the Improving Seniors’ Timely Access to Care Act of 2019. The legislation proposes the establishment of an electronic prior authorization program and would require health plans to provide CMS with information on their prior authorization use, as well as rates of denials and approvals. The bill also mandates that health plans explain why prior authorizations are needed. The bi-partisan bill supports increased transparency and automation around prior authorization processes used by Medicare Advantage (MA) health plans to approve medical services for their members. Arguing that the existing requirements of aggressive prior authorization limit access to care, the bill seeks to protect MA beneficiaries from prior authorization requirements that might delay or deny access to medically necessary care.

While there may be conflicting opinions amongst industry stakeholders, ultimately, this bill is critical for the timely and efficient care of patients. In a 2018 American Medical Association survey, 91 percent of healthcare providers reported delays stemming from prior authorizations. By requiring real-time electronic prior authorization for services routinely approved, patients will get access to the care they need more quickly. For example, the proposed legislation includes a ban on prior authorization requirements for certain procedural decisions made in time-sensitive situations, such as while a patient lies on the operating table.

Further, automating prior authorization will help to reduce waste from the healthcare system. Prior authorization can be a complex workflow that takes time and limits efficiency, resulting in significant administrative burden on clinical and non-clinical staff across the care continuum. For example, by streamlining these processes a discharge manager can be involved in critical clinical decisions about patient care, instead of working to track down paperwork required for prior authorization.

At CarePort, we are always supportive of efforts that ensure patients get the appropriate level of care when they need it. Improving efficiency and quality across healthcare settings is important, and will result in better outcomes for patients and reduced costs to the system. By leveraging real-time data from the largest end-to-end network of acute and post-acute providers in the US, CarePort solutions are being used to streamline the prior authorization process today, in addition to readmission prevention, reduced acute and post-acute length of stay, and more.

Interested in learning more on how CarePort can help you streamline the prior authorization process? Reach out.

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