From the Editorial Board: Charles N. Kahn III, MPH

ABSTRACT

Appealing prior authorization decisions is frequently onerous and disheartening for patients as well as their providers—indeed, few Medicare beneficiaries and providers pursue such appeals.2 In September 2018, the HHS Office of Inspector General (OIG) reported on Medicare Advantage (MA) plan prior authorization policies and appeals.2 The OIG found high rates of overturned prior authorization and payment denials and identified problems related to denials of care and payment. [...]as managed care plans consider their postpandemic policies, they should examine the impact of prior authorization requirements, including on access to postacute care. Actions to reduce the burden of prior authorization, interfere less with patient care, save administrative costs, and better target overuse, waste, and abuse include * ensure prior authorization decisions are timely and negative determinations indicate the reason for the denial;* sunset programs with very high approval rates;* improve transparency by providing detailed information on prior authorization policies and tracking and reporting rates of approvals and denials;* increase standardization of prior authorization policies, operations, and forms through the use of electronic transmission of prior authorization requests;* ensure prior authorization programs adhere to evidence-based medical guidelines and include continuity of care for individuals transitioning between coverage policies;* eliminate additional prior authorization for medically necessary services performed during a surgical procedure that already received, or did not initially require, prior authorization;and * establish "gold carding," under which payers reduce prior authorization requirements for providers that have demonstrated a consistent pattern of compliance, improving efficiency and resulting in more prompt delivery of health care services.