Prior authorization practices and protocols have changed among many major payers in the last year.
Here are 10 things for ASCs to know regarding prior authorization in 2024:
1. CMS updated its interoperability and prior authorization final rule at the beginning of the year. The rule requires payers to implement features including adding information about prior authorizations to their patient access interfaces, creating provider access interfaces to share patient data, claims and prior authorization information, and the requirement for prior authorization decisions to be made within 72 hours.
2. Ninety-seven percent of providers have had delays or denials for necessary patient care due to prior authorization requirements, according to the Medical Group Management Association's 2023 "Regulatory Burden Report."
3. In the same report, 97% of respondents said a reduction in regulatory burden would allow them to reallocate resources toward patient care.
4. A survey by the American Medical Association found that 33% of physicians said delays in processing a prior authorization led to a serious adverse event for a patient in their care.
5. The same survey found that physicians and their staff spend 14 hours a week, or almost two business days, on prior authorizations.
6. A report from KFF found that 16% of insured adults have faced prior authorization issues in the last year, and among Medicaid beneficiaries, that percentage was even higher (22%).
7. The administrative costs of healthcare, including prior authorizations, are estimated to make up 20% to 34% of healthcare expenditures, according to a report from the American Enterprise Institute, a public policy think tank.
8. Payers including Humana, Cigna Healthcare, Blue Cross Blue Shield of Michigan and UnitedHealthcare in 2023 initiated efforts to reduce or eliminate prior authorization requirements.
9. In April, CMS issued a final rule streamlining Medicare Advantage and Part D prior authorizations. The update focused on coordinated care plans and establishing utilization management committees to review policies annually to ensure prior authorization is used appropriately.
10. Recent prior authorization reforms are expected to save physician practices $15 billion over the next 10 years, according to Jesse Ehrenfeld, MD, president of the American Medical Association.