Track Changing Prior Authorization Requirements to Avoid Delays in Access to Care!

Coding & Billing

To reduce administrative hurdles that commonly delay access to care, prior authorization (PA) requirements related to COVID-19 screening, testing, and treatment are dynamic and changing for most U.S. insurers.  In addition, PAs for admissions, elective procedures, and transfers also are being updated.  The payers that have changing PA requirements include the national and regional private payers and their commercial employer-sponsored plans, Medicaid managed care, and Medicare Advantage plans.  It is important to keep track of the changing PA requirements because when a provider does not obtain a required PA, as indicated, the insurer often denies coverage and payment for the service, product, or procedure.

Key Recent PA Changes

It is important to note that during the pandemic, many key commercial payers are not requiring PA for “medically necessary treatment” for COVID-19 and for many Non-COVID-19 services.  Payers are covering pre-admission COVID-19 testing done in an outpatient setting.  Several national plans have also relaxed prior authorizations for some services in the post-acute care settings.

Most payers are still requiring PA waivers for elective procedures.  Providers are responsible for abiding by applicable state restriction guidelines on elective procedures.  Others are temporarily extending PAs on elective inpatient and outpatient procedures. While a 90-day extension is the trend amongst commercial payers, the extension’s duration varies by plan and insurance company.

Several states have taken actions to:

  • Remove prior authorization for COVID-19 testing and relax prior authorizations for some services,
  • Suspend prior authorization requirements for fee-for-service Medicaid under a 1135 waiver;
  • Require that prior authorizations granted before the emergency orders remain valid until the end of the public health emergency;
  • Suspend prior authorization requirements for Medicaid managed care plans;
  • Require health insurers to ease prior authorization for prescription medications in certain situations streamline, suspend, or eliminate processes for requesting prior authorization, step therapy exceptions, and exceptions;
  • Expand the timeframe for current approvals through the end of 2020;
  • Reduce prior authorizations that may delay discharge from a hospital; and

Suspend all prior authorization requirements for some services performed at hospitals, including lab work and radiology, until a specific deadline.  According to the American Medical Association (AMA), some pharmacy benefit managers are also waiving prior authorization.  PA for medication extension is limited to drugs with significant abuse potential, drugs dosed for finite durations, and newly prescribed medications.

What is the Importance of the Changing PA Requirements to the Industry?

It is important for accounts to track the PA requirements to avoid denials of care and delayed access to care. 

Medical device, drugs, diagnostic, and other medical technology manufacturers should consider:

  • updating their Billing Guides with the new payer requirements
  • educating the accounts about contacting payers to verify PA requirements
  • tracking PA requirement and providing PA assistance with the help of safe medical technology hotline services.

The GIRS InContact Reimbursement Hotline® team has over 17 years of experience assisting account with PAs and conducting benefit verifications.  The GIRS Payer Advocacy Compass PAC® works with the medical technology hotline service to address non coverage issues and to track payer market trends and policies in an integrated way.  We also educate providers and stakeholders about changes to ensure coverage and reimbursement of our clients’ medical technologies thereby providing the best reimbursement outcomes by working both at the grass roots level and at the regional and national levels.

Please contact us  by email or avail or avail of our Complimentary Review of your reimbursement needs at girsinc.com

Sources:

About GIRS

For more than 17 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need.  To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, email us at info@girsinc.com or call us at 901-834-9119.

Disclaimer: The information in this blog is based on payer information which is dynamic.  It is accurate at the time of posting but should not be construed to be reimbursement or legal advice.  CPT® codes are the trademark of the AMA.