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Prior Authorization

Prior authorization (PA) is one of the most significant issues plaguing TMA members. The TMA team has been working with the major payers to address administrative burdens with an aim to reduce prior authorization hassles by health insurance plans and government payers. It has formed a workgroup to discuss these burdens and work toward resolution.

Payment rules and policies, third-party benefit managers, unilateral fee reductions, incorrect fee schedule loading, credentialing delays, one-sided contractual terms, increased prior authorization demands, recoupments, policies that drive income out of state, etc. are just a few of the many challenges physicians face within their practices. All of these issues directly affect patients by limiting access to care and causing delays in treatment. Patient compliance is decreased and reimbursement is often delayed or denied due to these administrative burdens.

Why is this issue important? Administrative burdens exasperate physician job satisfaction and contribute to professional burnout both personally and financially. Physicians want to spend more time caring for their patients and less time jumping through hoops to do so.

TMA needs your help. In order to identify systemic issues, we are asking practices to provide examples of egregious behavior you or your patients have experienced due to the prior authorization process. Also, please let us know the extent of your overhead costs related to prior authorization so your patients are able to get the care they need. We must have concrete, specific and detailed examples to work toward resolution so it is imperative that you take time to give us this information.

TMA's Prior Authorization Workgroup

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 agreed upon by the payers over three years ago. TMA and the payers continue to work collaboratively toward finding solutions to this onerous process. To our knowledge, we are the only State Medical Association that has put together a forum to find ways to implement the statement.

The workgroup has been meeting monthly since July 2020. 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.

TMA will be hosting a series of webinars to educate providers on the prior authorization process and offer solutions to difficult situations. Below are the dates and list of payers. Each webinar will take place at at 10:00 am CT. 

Register Here

  • Jan. 19: Blue Cross Blue Shield of Tennessee
  • Jan. 26: Ambetter
  • Feb. 2: Cigna 
  • Feb. 9: Aetna 
  • Feb. 16: United Healthcare 
  • Feb. 23: Humana

 

Prior Auth Experience Form

Have you had an experience with prior authorization? We'd like to hear about it.

Share Your Experience

 

Contact Us

Karen Baird, CPC, CPMA
Director of Insurance Affairs
karen.baird@tnmed.org
615.460.1651