TMA Creates Prior-Authorization Workgroup


September 28, 2021

Nashville, TN — Prior Authorization (PA) is one of the most significant issues TMA members face. This workgroup was formed out of discussions in TMA’s Insurance Issues committee with the intention of working together with stakeholders to identify and respond to prior authorization challenges without bringing legislation. The AMA Consensus Statement was used as the foundation for discussions. The Consensus Statement was written by the AMA and was agreed upon by the payers over three years ago; however, there has been little to no progress by the payers to date.

The workgroup has been meeting monthly over the last 15 months. It includes TMA’s Insurance Issues Committee chairperson, the assistant insurance commissioner, major payer medical directors and subject matter experts, practice administrators, a practice consultant, and a representative from the American Medical Association (AMA), and America’s Health Insurance Plans (AHIP). Discussions have included the PA process during credentialing and contracting, gold carding, and reducing the number of PAs required.

The group first discussed PA during the credentialing and contracting phase. Credentialing and contracting run concurrently with most payers. Standard rate contracts run smoothly; however, the process takes longer when practices negotiate their contracts. The payers state that incomplete applications take additional time and providers often take too long to provide the requested information. Therefore, it is imperative to provide the additional information in a timely manner to move the application forward.

Gold carding has also been discussed. This is where physicians get a reprieve from the usual PA process if they have a high PA request approval rate and adhere to evidence-based medicine. United Healthcare’s Premium Designation Program is a type of gold carding. The other major payers do not offer such programs. The payers state that approximately 85% of their business is self-funded and the employer groups are the ones requiring utilization management to keep the cost of premiums down. TMA is advocating for gold carding but also for a reduction in the number of procedures and medications that require PA.

The payers have an automated process to initiate PAs and feel this is the fastest way to obtain an approval or a denial. Most automated PAs revolve around hi-tech imaging (e.g., PET scans, MRIs, and CT scans). However, surgical procedures also require PA and are administratively burdensome for practices. Recently, Cigna began a pilot project with a Tennessee surgical practice to possibly include certain surgical procedures in their EviCore automated PA algorithms. This would not have come to fruition without TMA’s insurance advocacy.

TMA will be hosting an “All Things Prior-Auth” series of webinars. It will highlight one major payer per week. Each payer will discuss everything related to their PA processes and provide useful information to help relieve some of the frustration you face day to day in your practice. Stay tuned for dates and more information.

TMA has multiple resources available to its members. The legal department has researched hundreds of issues and created an informative Law Guide. The Law Guide topics include issues such as COVID Liability Protection, Credentialing, HIPPA, NPP Supervision, Prompt Pay, Recoupments, and much more. The legal team can be reached at legal@tnmed.org should you have questions related to legal issues.

If you are experiencing PA burdens or need assistance with insurance hassles, please contact TMA’s Director of Insurance Affairs Karen Baird. She can be reached by email at karen.baird@tnmed.org or 615-460-1651.