Improving the Prior Authorization Process: Recommendations for California

Funded by the California Health Care Foundation, NEHI engaged California payers, providers, consumer advocates, and regulatory agency officials to understand the top issues around the prior authorization process:

• The lack of information on prior authorization requirements at the point of care adds to the cost of prior authorization for providers and payers.
• Data about the prior authorization process and its impact are not shared publicly or at actionable levels.
• Repeat prior authorizations and concurrent reviews during a course of treatment interrupt patient care and may expose patients to financial liability.
• Prior authorization requirements are not well understood by patients or providers, resulting in the percep­tion that there are “too many” prior authorizations.
• A perception exists among providers and patients that medical necessity determinations for certain types of complex care are made by health care professionals without the requisite expertise.

Based on an interim NEHI report (detailing California’s health care landscape as well as federal, state, and voluntary prior authorization reform efforts over the past decade) and California stakeholder input on feasible methods to alleviate current issues, NEHI developed specific recommendations for prior authorization process improvement in the following areas:

• Mandate technical requirements to advance adoption of automation.
• Refine public reporting requirements to pro­mote trust and enable dialogue about additional reforms.
• Extend the duration and scope of prior authorization approval for ongoing care with a defined and accepted course of treatment.
• Develop transparent principles for the annual review of prior authorization requirements.

Read the full report to learn more about the different approaches California could consider in improving the prior authorization process.