What ASCs need to know about prior authorization 

Here are 12 updates in the last year about prior authorizations, one of the biggest burdens for ASC leaders. 

1. In December, CMS issued a new proposed rule to streamline prior authorization for medical items and services.The rule would require certain payers to implement electronic prior authorization, shorten time frames for certain payers, and establish processes that make prior authorization more transparent and efficient.

2. Seventy-nine percent of medical groups said that payer prior authorization requirements increased in the last year, according to a March poll conducted by the Medical Group Management Association.

3. Many ASC leaders say prior authorization is one of the biggest issues in the industry. 

"My biggest industry concern is the ever increasing barriers by payers to provide high value care to our most vulnerable patients in a timely fashion," Kenneth Nwosu, MD, spine surgeon at NeoSpine in Puyallup, Wash., told Becker's. "Over time, it appears that the default decision for procedures needing prior authorization is a denial, as indicated by a rising number of peer-to-peer reviews where the reviewing physician openly states that the ordered surgery should not have been denied. Alternatively, I am seeing more denials where a peer-to-peer review time is dictated by the payer, which is often in conflict with the treating physician's availability. In some instances, there is not an option to partake in a peer-to-peer review following a denial."

4. Eighty-two percent of group practice executives say prior authorization is very or extremely burdensome, according to the Medical Group Management Association's "Annual Regulatory Burden Report."

5. The Medical Group Management Association on Sept. 12 penned a letter to CMS Administrator Chiquita Brooks-LaSure asking for certain provisions to be implemented to ease the economic burdens on physician practices, including prior authorization reform.  

6. CMS removed a type of corrective eyelid surgery from the hospital outpatient department prior authorization list Jan. 7. 

7. UnitedHealthcare now requires members to obtain prior authorization before undergoing physical and occupational therapy at multidisciplinary offices and outpatient hospitals in four states.

8. Thirty-four percent of physicians reported that delays in processing a prior authorization led to a serious adverse event for a patient in their care, according to a February survey from the American Medical Association. 

9. UnitedHealth Group has decided to stop mailing prior authorization and clinical decisions to providers on paper.

10. Thirteen percent of denied prior authorization requests made by Medicare Advantage organizations met Medicare coverage rules, according to a review conducted by the HHS Office of Inspector General released in April. 

11. Aetna will no longer require prior authorization for cataract surgery and video electroencephalography procedures. 

12. California's Health Care Services Department issued a notice that removed prior authorization requirements for most drugs under Medi-Cal, the state's Medicaid program. 

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