Prior Authorization Changes Driven by the COVID-19 Pandemic

By Robert Popovian & Amanda DeMarzo

Many hospitals have shifted staff resources from administrative functions to direct patient care due to the increased demand for inpatient hospital services for COVID-19 patients. A temporary suspension of elective surgeries and a reduction of non-time-sensitive procedures has also reduced the need for many administrative positions in hospitals.^1,2 This reduction in administrative staffing and the high demand on hospitals has made it difficult to process the paperwork insurers require for prior authorizations (PA), reviews for medical necessity, and retrospective reviews.^1,2

Health care associations, particularly those representing physicians and hospitals, have expressed concern regarding the current high demand on healthcare resources.^2,3 They have asked health insurers, as well as local and federal governments, to take action and reduce the administrative burden of the current insurance infrastructure.^2,3 The American Medical Association (AMA) drafted policy options for states to implement in light of the COVID-19 pandemic.² The draft policies include prohibiting PAs for COVID-19 testing, all related services, and medication alternatives necessary due to shortages.² The policies drafted by the AMA also include extending approved PAs for surgeries delayed due to the pandemic and prohibiting PAs for emergency care irrespective of the circumstances.² The American College of Cardiology issued a letter to insurers expressing their concern over the severity of the COVID-19 pandemic. They recommend payers and PA vendors suspend restrictions and barriers on cardiovascular imaging tests and initial cardiac stress tests.³

On March 18, 2020, the federal government passed the Families First Coronavirus Response Act (FFCRA), requiring health insurance companies to waive cost-sharing charges for FDA-approved COVID-19 testing, including copayments, co-insurances, and deductibles.⁴ The Act also waives cost-sharing for telehealth services, in-person doctor visits, urgent care visits, and emergency room visits related to COVID-19.⁴ A few states (Kentucky, Maine, Maryland, Massachusetts, and Rhode Island^7-11) have implemented laws requiring health insurers to waive PA requirements for COVID-19 related emergency room visits, healthcare, and prescriptions.^5,6 Most states have instead recommended or encouraged insurers to waive PAs for COVID-19 related medical care.^5,6 The regulations passed by individual states have mirrored the FFCRA Act passed by Congress in waiving cost sharing for COVID-19 testing.^5,6

Epicenter Response

One state choosing to encourage, rather than mandate, that insurers temporarily waive PAs is New York State (NYS). With elective surgeries temporarily cancelled, NYS has issued an industry guidance advising insurers to suspend preauthorization review for scheduled surgeries or admissions at hospitals for 90 days from March 20, 2020 during the state of emergency.¹ Hospitals are advised to provide 48 hours’ notice to insurers after admission, including all necessary information for insurers to assist in coordinating care and discharge planning.¹ The guidance also advises insurers to suspend concurrent review for inpatient hospital services for 90 days from March 20, 2020.¹ A concurrent review occurs when an insurer receives notice of continued or extended health care or similar service and is provided one business day to collect additional information and make decisions regarding medical necessity and coverage. The guidance also advises insurers to pay claims from in-network hospitals without performing a retrospective review for 90 days from March 20, 2020.¹ NYS recommends that their normal window of one month to perform retrospective review be extended to cover the previous 3 months.¹ This is important as it temporarily allows hospitals to shift resources spent on administration and billing to healthcare while still allowing insurers to review services for medical necessity and cost.

Insurers Respond to the Pandemic

Below is a chart summarizing key policy changes major insurance companies have implemented related to PA in response to the COVID-19 pandemic.

Insurer	Response5,6
Aetna	·        PA waiver for transfer to acute care facilities ·        PA reinstated May 31, 2020 ·        Home health does not require PA
Anthem	·        PA suspended for patient transfers (duration is state-                specific) ·        PA suspended for medical equipment critical to COVID-           19 treatment
BCBS	·        Response is state-specific ·        PA waiver for transfer to acute facilities in many states ·        Waived PAs for diagnostic tests and refill limits on                      maintenance meds
Cigna	·        PA waiver for transfer to acute care facilities ·        PAs reinstated May 31, 2020
Emblem	·        PA waived for all inpatient admissions ·        PA waived for refill limits on maintenance meds ·        Extended grace period for non-payment of premium ·        PAs reinstated June 18, 2020
Humana	·        PA for services suspended on April 1, 2020 ·        PA reinstated due to decreased demand May 22, 2020
UnitedHealthcare	·        90-Day extension on all existing approved PAs ·        PA waived for discharges to acute care facilities ·        PA waiver effective March 24, 2020 – May 31, 2020. ·        Improved patient access by allowing members to call                and speak to a pharmacist.

PA: Prior Authorization

UnitedHealthcare

United Healthcare has responded to guidance issued by states across the country by providing a 90-day extension on all existing approved PAs.¹² All COVID-19 discharges to home-based care requiring a respiratory assist device or a ventilator will not require a PA for the device as long as United Healthcare is notified within three months; this also applies to oxygen deliveries.¹² Post-acute care settings such as long-term acute care facilities, skilled nursing facilities, and acute inpatient rehabilitation will not require PAs for admission.¹² No prior authorizations will be required for diagnostic radiology or imaging of the chest for COVID-19 patients.¹² The waiving of these PA requirements was from March 24 through May 31, 2020.¹² No longer having to wait for approval, hospitals can now discharge their patients faster.¹² UnitedHealthcare has expanded patient access by allowing members to call and speak to a pharmacist to get an early refill on their prescriptions due to the pandemic; normally the availability of this allowance is plan-based.¹² UnitedHealthcare will also monitor the availability of medications and shortages and cover alternatives as needed.¹²

United Healthcare
Summary of Waived PAs & Other Waivers (March 24 to May 31, 2020)¹²

• Discharges to home-based care requiring respiratory assist device or ventilator
• Oxygen deliveries
• Discharges to post-acute care settings
• Diagnostic radiology and imaging of the chest for COVID-19 patients
• Transfers to a new provider
• Waived cost sharing for COVID-19 in and out of network visits
• Waived cost sharing for non-COVID-19 visits in-network for fully insured commercial, Medicare Advantage, and Medicaid plans

Humana

Humana also responded by suspending most PA requirements, referrals, and medical record claims review effective April 1, 2020. Initially, Humana did not set an end date for their suspension.¹³ Like UnitedHealthcare, Humana has extended previously approved PAs by 90 days.¹³ The suspension covers nearly all PA requirements for participating in-network providers as well as inpatient, outpatient, and referrals for all plans.¹³ Out-of-network providers and retail pharmacies must still follow prior authorization requirements.¹³ With many states reopening and lifting the ban on elective procedures, Humana has seen a sustained increase in procedure and admissions volume. Effective May 22, 2020, all PAs, referrals, and medical record claims reviews have been reinstated.^13,14

Emblem Health

Emblem Health also waived PA and concurrent review for all inpatient admissions.¹⁵ In response to the guidance issued by states like New York, Emblem has waived standard PA, concurrent review, retrospective review, and discharge planning services for inpatient hospital and emergency services for 90 days ending on June 18, 2020.¹⁵

Cigna

Cigna also waived all out of pocket costs for COVID-19 testing and related visits with in-network providers through May 31, 2020.¹⁶ PAs will be waived for the transfer of non-COVID-19 patients from acute inpatient hospitals to in-network long term acute care hospitals to help manage the demands of increasingly high volumes of COVID-19 patients being admitted.¹⁶

Blue Cross Blue Shield

Blue Cross Blue Shield Association (BCBS) has announced that its network of 36 independently-operated BCBS companies will waive PAs for diagnostic tests and covered services for COVID-19, waive prescription refill limits on maintenance medications, and waive cost sharing.¹⁷ Each state has responded differently; however, in many states PAs for transfers or admissions to acute or long term care facilities have been waived.¹⁷ Fidelis, a Medicaid plan, is also waiving all COVID-19 related PA requirements and member cost sharing for related screening, testing, and treatment.¹⁸

Federally Funded Payer Response

The federal government’s Centers for Medicare & Medicaid Services (CMS), which provides funding to individual states and regulates the provision of Medicaid services, has allowed individual states to apply for waivers for leniency.^20,21 The federal government had issued waivers to twenty-three states as of March 26, 2020. These waivers provide relief on several fronts – PA, provider enrollment requirements, and suspending certain nursing home pre-admission reviews for Medicaid patients. Each state may ask for waivers for what it deems necessary.²⁰ These waivers, unless otherwise specified, are effective retroactively from March 1, 2020 and will terminate upon termination of the public health emergency.^20,21

CMS has also issued information on obligations and permissible flexibilities to insurers who provide Medicare Advantage and Part D plans, to take effect once individual Governors declare a state of emergency. The CMS directs these plans to waive PA requirements, waive cost sharing, waive referrals, cover out-of-network services, and make changes to their plan which benefit the enrollee. This would be effective until the end date of the state of emergency, or for 30 days if the Governor does not provide one.²²

Other Responses

Pharmacy coverage provider Express Scripts has not followed the example set by medical insurance providers, as their standard PA policies still remain in place.¹⁹ Instead, Express Scripts has promised to monitor the COVID-19 situation and to update policies if the situation changes.¹⁹ OptumRx, on the other hand, has implemented a one-time 90-day extension of all existing PAs set to expire on or before May 1, 2020.²³

Time to Catch Up

The federal government took the first step in relieving the financial burden of healthcare on individuals and, to a lesser extent, the administrative burden on hospitals during the COVID-19 pandemic by waiving cost-sharing.⁴ However, this was not enough and hospitals struggled to meet high demand.¹ Medical associations and hospitals requested state governments and insurers to intervene and help expedite healthcare by waiving PA requirements for the administration of healthcare and for the transfer of patients out of hospitals and to rehab facilities.^2,3 Few states have responded by requiring insurers to waive PAs. Instead, states have issued guidance and recommendations for insurers to implement these policies.^1,5,6 Most insurers have responded by waiving and extending PAs for approximately 90 days.^5,6

As states begin to reopen and hospitals return to normal, insurers have begun to reinstate PA requirements.^5,6 Insurance companies will begin retrospectively reviewing paid claims and requesting documents from hospitals. This means that hospitals will have to shift their resources back to administrative functions. Healthcare systems are learning how to manage and return to normal daily functions as the COVID-19 pandemic subsides. Will your health system be able to keep up with the surge of retrospective claim reviews?

Burden on Healthcare

PAs are not a new burden for the healthcare system. The pandemic barely eased the high burden that 75% of physicians experience regularly.²⁴ As seen through the variable pandemic response, payers all had different policies and procedures around the waiving of PA requirements. Policymakers, regulatory agencies, and professional organizations made recommendations to ease the challenges of the pandemic, but only some payers listened. Now that states are opening back up, the reimbursement process is back to business as usual.

If asked, most stakeholders (physicians, office staff, nurses, pharmacists and patients) would probably agree that their opinion of the pre-certification and PA workflow process is not a positive. The PA process is convoluted on the best of days and a global pandemic did not ease that process. An AMA survey showed that physicians spend 16 hours or more on PA requests each week, taking away time from patient-facing encounters.²⁴

The AMA has been petitioning for changes to the PA processes for years with little meaningful progress for stakeholders nationwide. PAs continue to increase year after year, requiring dedicated staff for short-term mitigation and legislation for long-term resolution. To support reform of the PA process, AMA has launched a grassroots effort targeting healthcare professionals and patients: #FixPriorAuth https://fixpriorauth.org/.

As recently as this year, state-level reform has taken effect in Kentucky and Maryland. In Kentucky, physicians must receive responses within twenty-four hours for urgent requests and five days for nonurgent requests; prescriptions for chronic maintenance medications are valid for one year including changes in dosage; insurers must provide resources online about PA processes and services requiring PA; and the authorizers must be physicians in the same specialty as the requesting physician. Additionally, Maryland now requires insurance carriers to honor PA from a previous insurer for the first 30 days of the new plan; dosage changes and PA requests are honored with plan changes; and insurers must notify patients and HCPs of PA changes implemented. These states provide different pictures of reform for the PA process, but both methods can ease the burdens for patients and providers.

With bills championed by healthcare professionals such as General Assembly Delegate Terri Hill, MD, a Maryland surgeon, and State Senator Ralph Alvarado, MD, a Kentucky internist and pediatrician, legislative change can reduce the burden of PAs on the healthcare system. Further progress on legislative reform of the prior authorization process is necessary to ensure patients receive appropriate access to the care they and their physicians have determined is best.

One way for healthcare professionals and their staff to tackle the complicated prior authorization landscape is to pursue a certification as a Prior Authorization Certified Specialist (PACS) offered by the National Board of Prior Authorization Specialists (NBPAS).

Conclusion

No one is arguing that the PA should not be used at certain times to ensure appropriate use of healthcare services and medicines. However, a complicated and arbitrary PA scheme imposed upon the healthcare system does not help patients. We should strive for a real time, online and transparent PA mechanism that does not inappropriately delay care for patients.

By Robert Popovian & Amanda DeMarzo

Robert Popovian, PharmD, MS, is the Vice President, US Government Relations, Pfizer

Amanda DeMarzo, PharmD, MBA, is  Associate Director, Patient Access, Accreditation Council for Medical Affairs

References

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