Summary: Prior Authorization Changes Driven by the Covid-19 Pandemic
Amanda DeMarzo
Dec 18, 2020
7 minutes read
The severity of the COVID-19 pandemic has changed the way hospitals can manage the administrative burden of prior authorization due to an increased demand for direct patient care services. Insurance companies are asked to waive prior authorizations for a variety of medications and services during this time. The American Medical Association designed policies to reduce administrative tasks during the pandemic that states could implement such as prohibiting prior authorizations for all COVID-19 testing and related medication and services, all emergency services, and extending approved prior authorizations for surgeries delayed due to the pandemic. The federal government passed the Families First Coronavirus Response Act on March 18, 2020, which requires health insurance companies to waive copayments for COVID-19 testing, telehealth services, in-person doctor visits, urgent care visits, and emergency care visits relating to COVID-19.
Most states do not require, but only recommend that health insurance companies waive any prior authorizations related to COVID-19.
Kentucky, Maine, Maryland, Massachusetts, and Rhode Island are among those states that have enacted laws that require health insurance companies to waive prior authorization requirements for all COVID-19 related emergency room visits, healthcare, and prescriptions. New York was one of the many states that only encouraged insurers to waive or suspend PAs for a limited time. NYS encouraged states to waive PAs for surgeries and admissions, suspend concurrent review for inpatient services, and pay claims from in-network hospitals without performing a retrospective review for 90 days from March 20, 2020. Insurers have the liberty to implement or not implement these suggestions.
United Healthcare’s PA waivers lasted from March 24th through May 31st and included a 90-day extension on all existing approved PAs, a PA waiver for discharges to acute care facilities, and suspending PAs for diagnostic radiology or imaging for COVID-19 patients. Because hospitals did not have to wait for PAs, they were able to discharge patients faster. Patients may also call pharmacists to get early refills due to the pandemic.
Humana also waived PA requirements, referrals, and medical record claims from April 1st to May 22nd, 2020. These waivers applied to most of their in-network providers as well as inpatient, outpatient, and referrals for all plans. Ending after 90 days on June 18, 2020, Emblem Health waived standard prior authorizations, concurrent review, retrospective review, and discharge planning for hospital and emergency services. Emblem also waived PAs for refill limits on maintenance medications for its members. Cigna waived PA requirements to transfer non-COVID-19 patients from acute inpatient hospitals to in-network long term acute care hospitals and all out of pocket costs for COVID-19 related testing and visits for in-network providers through May 31st, 2020. Blue Cross Blue Shield waived COVID-19 related diagnostic tests and services, prescription refill limits on maintenance medication, and cost-sharing.
Most states also waived PAs for transfer to acute facilities. Fidelis waived all PA requirements for COVID-19 related screening, testing, and treatment. CMS has provided waivers to 23 states starting March 1st, 2020 regarding PAs, provider enrollment requirements, and pre-admission reviews for nursing homes. They also instructed insurers who provide Medicare Advantage and Part D plans to waive PA requirements, cost sharing, referrals, and cover out-of-network services to benefit the member. OptumRx implemented a 90-day extension for existing PAs which expired on May 1st, 2020.
Prior authorizations are not favored by physicians, office staff, nurses, pharmacists or patients and the pandemic did little to alleviate this administrative burden due to the varied responses from different states and insurers. Once states opened back up, the reimbursement process went back to normal, even though the pandemic is ongoing. This has forced hospitals to shift their resources back to managing administrative tasks like PAs. The number of required prior authorizations increase yearly, to the dismay of the American Medical Association who have been petitioning for changes to the system. The NBPAS offers a certification program known as The Prior Authorization Certified Specialist (PACS) to help healthcare professionals better understand the PA system.
Although prior authorizations are undoubtedly an important tool to reduce unnecessary health care costs, a complicated system does not help patients and only serve in delaying care. Prior authorizations should be managed through a straight-forward online electronic system that shows changes in real-time.
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The assistance of Rhea Thomas, PharmD candidate 2021 is gratefully acknowledged in the preparation of this article.
