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May 30, 2017

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House Ways and Means Medicare Hearing

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State Corner: AAOS, 25+ Organizations Sign onto Prior Authorization Reform Principles

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State Corner: AAOS, 25+ Organizations Sign onto Prior Authorization Reform Principles

In April, more than 25 organizations – including the American Association of Orthopaedic Surgeons – representing physicians, medical groups, hospitals, pharmacists and patients set forth a comprehensive set of 21 principles in an attempt to combat prior authorization requirements.

The coalition strongly urges health insurers and middlemen utilization-review entities, along with accreditation organizations and lawmakers, to apply the agreed upon principles to their prior authorization programs for all surgical care. Further, AAOS will ask that physicians that participate in a financial risk-sharing payment plan should be exempt from prior authorization altogether.

Last year, the Ohio Orthopaedic Society and a broad coalition of provider and patient groups were successful in lobbying similar principles through legislation at the Ohio state legislature. They supported the introduction of Senate Bill 129, which eventually passed, to remedy many of the basic issues around prior authorization. SB 129, the Prior Authorization Reform Act, will make several changes to the prior authorization system in Ohio; First, it creates a uniform web-based system through which to submit prior authorization requests. It establishes time-frames within which a prior authorization request must be responded to. The bill ensures once a prior authorization has been secured, an insurer is not able to retroactively deny coverage for that authorization. All new or future prior authorization requirements are disclosed to the provider community at least 30 days in advance. The bill guarantees turnaround on prior authorization requests and quicker turnaround for more urgent requests. It mandates that prior authorization protocols use evidence based clinical review criteria. And finally, it creates a streamlined appeals process in cases where a prior authorization is denied.

To read the principles, click here.