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Prior Authorization

Prior authorization is the number one cause of burdens to physicians and other health care professionals when it comes to care delivery. These resources provide tips and solutions to help practices mitigate the burdens of prior authorization.

ACP Toolkit (published October 2023) addresses Prior Authorization reform and provides a comprehensive overview of the policy landscape and ways individuals can help advocate for reform at the state and federal levels.

What ACP is Doing

• ACP and ACP OH Joint Letter on HB 130, Prior Authorization Exemption (6/6/2024)
• ACP Statement to House Ways and Means Committee Health Subcommittee Hearing on the Collapse of Private Practice: Examining the Challenges Facing Independent Medicine (5/23/2024)
• (4/19/2024)
• (3/5/2024)
• (12/4/2023)
• (11/20/2023)
• (11/6/2023)
• (10/18/2023)
• ACP Statement in Response to the House Ways and Means Committee's RFI Regarding Improving Access to Health Care in Rural and Underserved Areas (10/5/2023)
• (9/15/2023)
• (5/8/2023)
• (3/13/2023)

ACP and Medicine Forward

Webinars

• Breaking Bad! Prior Auth Harms the Physician-Patient Relationship – This recorded panel, in collaboration between ACP and Medicine Forward, addresses problems and workflow solutions to address the burdens of prior authorization. (Recorded 5/31/2022, 1 hr. 28 min)
• Breaking Bad Part II: ACP and Medicine Forward Advance Solutions for Prior Authorization – This recorded panel, in collaboration between ACP and Medicine Forward, offers solutions to the prior authorization problems addressed in the first Breaking Bad! webinar. (Recorded 10/03/2022, 1 hr. 30 min)

Drugs, Devices, and DME

Insurance companies require prior authorization for some drugs and devices to ensure appropriateness.

• – These 3 short videos from AMA address the advantages of using electronic prior authorization.
• – This tip sheet from AMA offers practical solutions and the pros and cons of each.
• – This 10-minute video series from the AMA outlines the burdens of the current manual PA processes, describes how pharmacy ePA can help improve prior authorization processing times, and explains how physicians can implement ePA in practice.

Imaging, Labs, Testing

• How to Avoid Peer-to-Peer Calls – When ordering imaging, prior authorizations go through radiology benefit companies, who are contracted by insurance companies. This video provides four key strategies to limit the number of calls required to obtain approval. (44 min)
• Laboratory & Imaging Test Ordering, Tracking, Results Review, and Reporting Results to Patients – This policy and procedures document was created to ensure timely and appropriate review of all laboratory and imaging results/tests ordered by the practice. 

Electronic Health Records

Electronic health records (EHRs) were created to streamline practice workflows and improve patient care, but often they also create burdens for health care practitioners. These resources are intended to provide tips and solutions on documentation, information sharing, and communicating using the patient portal to help practices mitigate some of these burdens.

Documentation

• State of the Note Summit 2021 – ACP worked with the EHR Association to develop tools to streamline clinical documentation, while avoiding “note bloat” and other burdensome documentation practices. These resources were intended to help physicians adapt to CMS’s 2021 E/M code changes and accompanying documentation requirements but are generally applicable to clinical documentation.
  • Primary Care Do’s and Don’t’s – Tips on how to streamline clinical documentation for general internal medicine physicians.
  • Medical Specialty Do’s and Don’t’s – Tips on how to streamline clinical documentation for specialists.
  • Five Recommendations for EHRs:
    1. Automatically write in SOAP, and review in APSO
    2. Combine Patient Instructions and Assessment and Plan
    3. Automatically expand abbreviations for patient-facing documents
    4. Allow linking out to data that is elsewhere in the EHR
    5. Allow for simple inclusion of discrete exam data
• – Resources defining key aspects of health IT and summarizing the potential benefits of integrating technology into practices to improve patient outcomes, including through health information exchange, which allows clinicians and patients to securely access and share a patient’s medical information electronically.

Information Sharing

• Information Blocking Key Terms and Acronyms – Key terms, definitions, and acronyms associated with regulations.
• Interoperability and Information Blocking Regulations – Resources regarding the ONC and CMS final regulations aimed at improving interoperability and patient access to EHRs.
• FAQ on Information Blocking: To Block or Not Block – Describes the various exceptions to claim and document if deciding not to share information.
• FAQ on Information Blocking: EHR and Health IT System Guidelines – Describes EHR functionality needed and highlights questions to ask your vendor.
• FAQ on Information Blocking: Patient Access – Describes how to address questions and concerns about patients’ increased access to health information.
• Use of Health Information Technology to Advance Patient Care – Explains the importance of practice staff understanding the appropriate use of technology.

Patient Portal Communication

• – Chapter of the ONC’s Patient Engagement Playbook that offers tips on optimizing use of the patient portal using staff, application programing interfaces, and other technology.
• Sample Patient Portal Agreement – Model for developing an agreement with your practice’s patients.
• Virtual Check-in or Online Digital E/M codes – Virtual check-in codes can be used for brief conversations where a clinician seeks to determine whether an in-person visit is necessary. Online digital E/M codes can be used for patient-initiated interactions via the patient portal.
• Team Care: Communicating with Patients – Sample policies and procedures for communication with patients; to be used as-is or edited to meet the needs of your practice.

What ACP is Doing

• (4/10/2024)
• (4/13/2023)
• (07/2021)
• (1/4/2021)
• (7/14/2020)
• Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations (06/2020)
• Comments on ONC’s Draft Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs (01/28/2019)
• (8/27/2018)
• (8/12/2019)
• (6/22/2018)
• (3/28/2017)
• (03/20/2017)
• (02/15/2015)

Prescribing Medications

Managing multiple medications and counseling patients regarding use, cost, and side effects can be time consuming. These resources provide tools to help clinicians, staff, and patients manage their medications.

• – Module that saves time and improves patient adherence.
• – Information about prescription assistance programs, free and low-cost clinics, government programs, and other assistance programs.
• – Information for consumers on drug-related topics including side effects, medication use, and medication fraud, etc., from the U.S. Food & Drug Administration.
• Medication Checklist
• Medication Adherence Inventory
• Medication Management & Electronic Prescribing
• (Video) – Dr. Marie Brown and receptionist Ms. Rockett describe one way to improve medication adherence.
• (ACP Internist Article and Video) – Martha Gray, MD, FACP, talks about increasing medication adherence.
• Substance Use Patient History
• - Information about Section 1262 of the Consolidated Appropriations Act of 2023 on the removal of the federal requirement for practitioners to submit a Notice of Intent to prescribe medications, like buprenorphine, for the treatment of opioid use disorder (OUD), from the Substance Abuse and Mental Health Services Administration (SAMHSA)
  • Drug Enforcement Administration (DEA)-registered prescribers must complete a one-time eight-hour on the treatment and management of patients with opioid or other substance use disorders starting on June 27, 2023.

What ACP is Doing

• (3/18/2024)
• (12/03/2019)
• (12/03/2019)

Private Payers

Private insurance companies and their differing policies, procedures, and payments add complexity to medical practice today. Visit our Private Payer page to learn more about what each individual payer is doing regarding behavioral and mental health, telehealth, prior authorization, value-based programs, Medicare Advantage, and more.

What ACP is Doing

• Sign-On Letter Regarding UHC's GI Endoscopy Prior Authorization Program (5/8/2023)
• (4/18/2023)
• - ACP met with UHC as part of their comprehensive effort to simplify the health care experience for consumers and providers. (3/29/2023)

Quality Reporting

The Quality Payment Program (QPP) aims to reduce burden and improve health outcomes for Medicare patients while rewarding high-value, high-quality Medicare clinicians. The QPP offers clinicians two tracks based on their practice size, specialty, location, or patient population. The Merit-based Incentive Payment System (MIPS) builds on traditional fee-for-service payments by adjusting them up or down based on performance. Alternative Payment Models (APMs) financially reward clinicians for delivering high-quality, cost-effective care. Learn more about quality reporting by visiting our QPP page.