CAQH CORE Approves 2-Day Limit for Prior Authorization Response

February 11, 2020 - CAQH CORE recently voted on a new rule to set a two-day time limit to speed up the prior authorization process, according to a recent press release.

Under the new rule, CAQH CORE participating organizations, which account for 75 percent of the insured US population, must request additional supporting information from providers and make decisions on prior authorization requests over a maximum of two days. This includes a two-day additional information request, a two-day final determination, and an optional close out.

“Prior authorizations serve as a check on the safety and appropriateness of medical treatments, but when they take too long, they can delay patient care,” Susan Turney, MD, CEO of Marshfield Clinic Health System and CAQH CORE board chair, said in the press release. “With today’s announcement, the industry has reached a compromise to ensure they are done efficiently.” 

In order to alleviate major burdens associated with prior authorizations, CAQH CORE participating organizations agreed to update requirements in the CAQH CORE 278 Prior Authorization Infrastructure Rule released in 2019. The update will improve information sent to the HIPPA-mandated standard electronic transaction and allow for faster responses.

The requirements of the updated rule must be met 90 percent of the time in a given month.

“These industry-led efforts will benefit all stakeholders, and patients in particular,” said Tim Kaja, COO of UnitedHealthcare Networks and CAQH CORE vice chair. “In 2020, CAQH CORE participants will continue working to improve the prior authorization process with a focus on how operating rules can streamline the exchange of medical documentation and support the use of new technologies with existing standards.” 

Under certain medical and prescription drug plans, specific services and medications need approval from health insurance agencies before they’re covered. Typically, these goods and services may be unsafe when combined with other medications, have a lower-cost option available, are often misused or abused, or are used for cosmetic purposes. 

Although prior authorization is a time-consuming process, some believe it is beneficial to patients to effectively manage drug costs and avoid any potentially harmful drug interactions. 

But 91 percent of doctors reported that prior authorization delays patient care access, according to a new survey from the American Medical Association. 

Of the 1,000 physician respondents that were surveyed, 28 percent also said prior authorization requirements led to serious or life-threatening health events. And 90 percent of respondents said prior authorization has negative consequences for patient care quality, which is most likely due to delay in care access.

Despite the challenges, prior authorization has continued to expand significantly during the last decade, a recent JAMA viewpoint article uncovered. Requirements of Medicare Part D plans increased 16 percent between 2007 and 2019, from 8 percent to 24 percent. Application of prior authorization on commercial formularies of single source drugs also increased from 35 percent of single source drugs approved for at least one year in 2011 to 67 percent in 2016. 

Some patients are unaware that further action approval is needed before arriving at pharmacies to pick up their medications and tend to drop off and forget about the medication altogether due to the lengthy authorization process. 

Thirty-seven percent of prescriptions initially rejected at the pharmacy are abandoned, never to be picked up by patients. This may explain why prior authorization has been linked to increased hospitalizations and medical costs for diabetes, depression, schizophrenia, and bipolar disorder.

The author of the article – a dermatologist from the University of California – recommended that health plans focus prior authorizations on its intended purpose. “Health plans should eliminate prior authorization requirements for medications that have very low final denial rates, lack evidence of unwarranted variation in utilization, or for which lower cost or safer but effective alternatives do not exist,” he wrote.

He also suggested that health plans limit prior authorization requirements to outliers with low approval ratings. A focus on continuity of care and requirement transparency would also help to alleviate the burdens of prior authorizations, he added.