Posted On September 30th, 2021
This NEHI white paper provides context and solutions for streamlining the prior authorization process.
The utilization management practice known as prior authorization (PA) has generated heightened controversy in recent years as payers and providers debate its benefits and burdens. Private and public health plans (payers) note that it is an essential part of their responsibility to ensure patient safety, decrease utilization of low-value care, avoid over-utilization of health care services, and direct care to appropriate, cost-effective health care settings. Providers reference administrative complexity and cost incurred in an effort to comply with a web of different requirements, lack of transparency in their development, and delays in patient care in their call to limit the services subject to PA. In this project, NEHI assembled a group of Massachusetts payers and providers, together with employer and patient representatives (the “Steering Committee”), to determine whether they could agree on a set of prior authorization solutions that might feasibly be implemented to reduce tensions around PA, considering a prioritized set of concerns. The Health Policy Commission and the Mass Collaborative provided funding for this work to continue their efforts to improve PA’s efficiency and effectiveness.
Nikita Agrawal, MPH, Policy Intern, NEHI
Kranti Rumalla, Policy Intern, NEHI