American Urological Association - AUA Adoption of AMA Prior Authorization and Utilization Management Reform Principles

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Home Guidelines Policy Statements Prior Authorization and Utilization Management Reform Principles

AUA Adoption of AMA Prior Authorization and Utilization Management Reform Principles

The American Urological Association (AUA) supports the American Medical Association Prior Authorization and Utilization Management Principles. 

As the leading advocate for the specialty of urology, the American Urological Association (AUA) supports initiatives that benefit patients by providing coordinated, continuous care and management of urologic disease. Not only do AUA members have concerns but medical providers across the country report that private and public insurer’s prior authorization requirements increase the burden on physicians and their staff and hinder patient’s timely access to appropriately prescribed medications and devices, which may result in delay of treatment.  In order to better serve our members and their patients, the AUA endorses the AMA Prior Authorization and Utilization Management Principles.

The Principles include:

Clinical Validity

  1. Any utilization management program applied to a service, device or drug should be based on accurate and up-to-date clinical criteria and never cost alone. The referenced clinical information should be readily available to the prescribing/ordering provider and the public.

  2. Utilization management programs should allow for flexibility, including the timely overriding of step therapy requirements and appeal of prior authorization denials.

  3. Utilization review entities should offer an appeals system for their utilization management programs that allows a prescribing/ordering provider direct access, such as a toll-free number, to a provider of the same training and specialty/subspecialty for discussion of medical necessity issues.

Continuity of Care

  1. Utilization review entities should offer a minimum of a 60-day grace period for any step- therapy or prior authorization protocols for patients who are already stabilized on a particular treatment upon enrollment in the plan. During this period, any medical treatment or drug regimen should not be interrupted while the utilization management requirements (e.g., prior authorization, step therapy overrides, formulary exceptions, etc.) are addressed.

  2. A drug or medical service that is removed from a plan’s formulary or is subject to new coverage restrictions after the beneficiary enrollment period has ended should be covered without restrictions for the duration of the benefit year.

  3. A prior authorization approval should be valid for the duration of the prescribed/ordered course of treatment.

  4. No utilization review entity should require patients to repeat step therapy protocols or retry therapies failed under other benefit plans before qualifying for coverage of a current effective therapy.

Transparency and Fairness

  1. Utilization review entities should publically disclose, in a searchable electronic format, patient-specific utilization management requirements, including prior authorization, step therapy, and formulary restrictions with patient cost-sharing information, applied to individual drugs and medical services. Such information should be accurate and current and include an effective date in order to be relied upon by providers and patients, including prospective patients engaged in the enrollment process. Additionally, utilization review entities should clearly communicate to prescribing/ordering providers what supporting documentation is needed to complete every prior authorization and step therapy override request.

  2. Utilization review entities should provide, and vendors should display, accurate, patient- specific, and up-to-date formularies that include prior authorization and step therapy requirements in electronic health record (EHR) systems for purposes that include e-prescribing.

  3. Utilization review entities should make statistics regarding prior authorization approval and denial rates available on their website (or another publically available website) in a readily accessible format. The statistics shall include but are not limited to the following categories related to prior authorization requests:

    • Health care provider type/specialty;

    • Medication, diagnostic test or procedure; Indication;

    • Total annual prior authorization requests, approvals and denials;

    • Reasons for denial such as, but not limited to, medical necessity or incomplete prior authorization submission; and

    • Denials overturned upon appeal.

      These data should inform efforts to refine and improve utilization management programs.

  4. Utilization review entities should provide detailed explanations for prior authorization or step therapy override denials, including an indication of any missing information. All utilization review denials should include the clinical rationale for the adverse determination (e.g., national medical specialty society guidelines, peer-reviewed clinical literature, etc.), provide the plan’s covered alternative treatment and detail the provider’s appeal rights.

Timely Access and Administrative Efficiency

  1. A utilization review entity requiring health care providers to adhere to prior authorization protocols should accept and respond to prior authorization and step-therapy override requests exclusively through secure electronic transmissions using the standard electronic transactions for pharmacy and medical services benefits. Facsimile, proprietary payer web-based portals, telephone discussions and nonstandard electronic forms shall not be considered electronic transmissions.

  2. Eligibility and all other medical policy coverage determinations should be performed as part of the prior authorization process. Patients and physicians should be able to rely on an authorization as a commitment to coverage and payment of the corresponding claim.

  3. In order to allow sufficient time for care delivery, a utilization review entity should not revoke, limit, condition or restrict coverage for authorized care provided within 45 business days from the date authorization was received.

  4. If a utilization review entity requires prior authorization for non-urgent care, the entity should make a determination and notify the provider within 48 hours of obtaining all necessary information. For urgent care, the determination should be made within 24 hours of obtaining all necessary information.

  5. Should a provider determine the need for an expedited appeal, a decision on such an appeal should be communicated by the utilization review entity to the provider and patient within 24 hours. Providers and patients should be notified of decisions on all other appeals within 10 calendar days. All appeal decisions should be made by a provider who (a) is of the same specialty, and subspecialty, whenever possible, as the prescribing/ordering provider and (b) was not involved in the initial adverse determination.

  6. Prior authorization should never be required for emergency care.

  7. Utilization review entities are encouraged to standardize criteria across the industry to promote uniformity and reduce administrative burdens

Alternatives and Exemptions

  1. Health plans should restrict utilization management programs to “outlier” providers whose prescribing or ordering patterns differ significantly from their peers after adjusting for patient mix and other relevant factors.

  2. Health plans should offer providers/practices at least one physician-driven, clinically based alternative to prior authorization, such as but not limited to “gold-card” or “preferred provider” programs or attestation of use of appropriate use criteria, clinical decision support systems or clinical pathways.

  3. A provider that contracts with a health plan to participate in a financial risk-sharing payment plan should be exempt from prior authorization and step-therapy requirements for services covered under the plan’s benefits. 

https://www.ama-assn.org/sites/default/files/media-browser/principles-with-signatory-page-for-slsc.pdf

 

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