Test Ordering & Utilization: Labs Stand to Benefit from Industry Efforts to Minimize Prior Authorization Red Tape

Although not specifically directed at labs, a new collaboration between the American Medical Association and insurance giant Anthem may offer solutions to a perennial thorn in the side of labs: payor prior authorization requirements of physician ordered treatments. 

The Consensus Statement
The seeds for the initiative were planted on January 17, 2018 when a group of leading health care organizations, including the AMA, American Hospital Association,  America’s Health Insurance Plans and the Medical Group Management  Association published a Consensus Statement outlining five areas where the stakeholders could work together to streamline and minimize the burdens imposed by the prior authorization process, including:

  • Selective application of prior authorization based on provider performance on quality measures and adherence to evidence-based medicine or contractual agreements such as risk-sharing arrangements;
  • Regular review of medical services and prescription drugs requiring prior authorization to identify therapies that no longer warrant prior authorization;
  • Transparency and effective two-way communication channels among plans, providers and patients to ensure timely resolution of prior authorization requests and minimize care delays;
  • Ensuring that prior authorization does not compromise continuity of care for patients undergoing treatment subject to changes in formulary, coverage or health plan; and
  • Industry-wide adoption of electronic prior authorization transactions based on existing national standards.

The AMA-Anthem Collaboration
On March 7, AMA and Anthem took the first concrete steps by announcing a collaboration designed to put the Consensus Statement principles into action. “Collaboration between payers and health care professionals is critical evolve and advance our health care system to one that is simpler, more accessible and more affordable for consumers,” noted Anthem, Inc. chief clinical officer Craig Samitt, M.D. “Today we are reaffirming our commitment to work together to create a best-in-class health care system that delivers on this promise for patients across the country.” said Craig Samitt, M.D., chief clinical officer at Anthem, Inc. “The AMA looks forward to finding common ground on ways to improve the delivery of affordable, high-quality, patient-centered care,” added AMA Board Chair Gerald E. Harmon, M.D.

In addition to streamlining prior authorization, the AMA/Anthem collaboration aims to achieve other broad goals to enhance the speed, efficiency and effectiveness of the health care system via improved payor-physician relations, including:  

  • Enhancing consumer and patient health care literacy; and
  • Development and implementation of value-based payment models for primary and specialty care physicians.

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