President's Column

Read archives from AAN Past President Orly Avitzur, MD, MBA, FAAN, who served from May 2021 to April 2023.

November 2022

AAN Advocacy Focuses on Prior Authorization Process: How You Can Help Now

Some of the most frustrating complaints I have heard voiced by neurologists and patients alike over the years are related to enduring the prior authorization (PA) process used by insurers to evaluate whether care is medically necessary and covered. Physicians, who average 41 such reviews a week—translating to almost two business days of physician and staff time according to a 2021 AMA survey, say it is a waste of time and inefficient use of health care dollars. Patients, who end up waiting to attain health care services such as imaging or to take prescribed medication, complain that delays in their care are sometimes so prolonged that it compromises their health or they give up in frustration. According to the Regulatory Relief Coalition, the process takes between two to 14 days, but for 15 percent of physicians, it can take from 15 to more than 31 days.

Brad C. Klein, MD, MBA, FAAN, who chairs the AAN Medical Economics and Practice Committee, knows all too well how the system consumes resources for neurologic practices. He cites the recent case of a patient for whom he prescribed ubrogepant (Ubrelvy) after failing triptan therapies which were on formulary. After an initial submission online, the insurance company requested additional information and required multiple duplicate resubmissions in both paper and electronic format subsequently. The process, which should have taken 10 minutes to complete, took 3.5 hours over several weeks instead. Sadly, it is being repeated in practices across the country on a daily basis.

The AAN has worked for many years to advance PA reform with Congress and the federal administration. We have engaged in many discussions with key stakeholders to champion the Improving Seniors’ Timely Access to Care Act of 2021(S. 3018/H.R. 3173), which would establish an electronic prior authorization (ePA) program; standardize and streamline the PA process for routinely approved services; reduce the amount of time an insurer is allowed to consider such requests; and ensure that they are reviewed by qualified medical personnel. The bill, advanced by the House Ways and Means Committee on July 27, 2022, and backed by the AAN and its coalition partners, has become one of the most supported bipartisan bills in Congress. It was selected for the priority agenda of two Neurology on the Hill events, and I am happy to report that this bill was passed in the House on September 14, 2022, and now awaits Senate action.

“Members may think that since it only pertains to Medicare Advantage plans, the legislation is not impactful,” said Dr. Klein. However, approximately 28.4 million beneficiaries now choose Medicare Advantage plans—45 percent of the Medicare population—which has doubled over the last decade. Between the passage of this law, which Dr. Klein hopes is imminent, and some successes with state efforts, progress is being made. Dr. Klein has tried in the past to get Gold Card access endorsed in Pennsylvania, where he practices, to exempt from PA physicians who are compliant and have a very low denial rate. He would like to see that and other initiatives assurance that patients can remain on medications that are working despite formulary changes; commitment by payers that formulary and authorization policy cannot change more than once yearly; increased transparency and a streamlined internet-based user interface to find policies and relevant criteria to obtain approvals in real time; and the removal of gag rules precluding pharmacies from informing patients about cost-saving sites like GoodRx.

Examples like the one Dr. Klein shared help in legislative advocacy. Shannon M. Kilgore, MD, FAAN, who serves on the AAN Board of Directors, said, “The AMA has created the website Fix Prior Authorization to collect patient and physician stories regarding adverse events related to delays in care which helped lead to the passage of the bill in the House.” Dr. Kilgore, who is the vice chair of the AAN delegation to the AMA House of Delegates, ensures collaboration between the two organizations along with other AAN members. She said, “Working with the AMA increases our chance of success on desired reform, which may be more difficult for the much smaller field of neurology to do alone.”

In the past, efforts to advocate directly with payers on PA failed to lead to substantive changes. It is clear that only legislative actions can ensure lasting change. Derek Brandt, director of Congressional Affairs at the AAN, said, “We were thrilled to have the Improving Seniors’ Timely Access to Care Act pass the House unanimously in September, but much more work is needed to get this bill over the finish line.” He urges AAN members who want to help get this done before Congress adjourns in December to contact their Senate offices. “We also expect many state bills focused on prior authorization to be considered early next year when local legislatures come back into session,” Brandt added. Because local advocacy can have a huge impact on an issue like this, he encourages members who would like to help advocate for change in their regions to connect with their state neurologic and medical societies, which typically coordinate such efforts within their states.

AAN resources for neurologists

The AAN has created resources to assist clinicians undergoing the prior authorization process such as insurance and prior authorization checklists. More recently, a PA Work Group of the Coding and Payment Policy Subcommittee created two disease-specific PA templates for CGRP inhibitors and botulinum toxin.

What you can do to help

• Contact your Senate offices.
• If you or your patients have stories that demonstrate the hazards of prior authorization, share them.
• Learn more about how BrainPAC helps advocate for this and other issues important to neurology at BrainPAC.org

Orly Avitzur, MD, MBA, FAAN
President, AAN
oavitzur@aan.com
@OrlyA on Twitter