March 25, 2020
3 min read

American College of Rheumatology calls for eliminating redundancies in prior authorization

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Virginia Reddy

The American College of Rheumatology has released a position statement advocating for sweeping changes to the current system of prior authorization, including reducing the number of rheumatologists and rheumatology professionals subject to the controversial practice.

“In addition to creating additional hoops for patients and providers to jump through, prior authorization diverts valuable time away from caring for patients and towards repetitive and time-consuming administrative tasks,” Virginia Reddy, MD, the statement’s lead author and member of the ACR’s Committee on Rheumatologic Care, said in a press release. “For patients with complex conditions like rheumatic disease, these delays may last weeks or even months and can be the difference between successful treatment or permanent joint damage and disability.”

The position statement, approved by the ACR board of directors in February, include five recommendations for reforming prior authorization practices. They include:

  • Eliminate prior authorization requirements in cases where the rheumatologist or rheumatology professional is already meeting performance measures, adhering to evidence-based practices and/or participating in a value-based agreement with a health insurance provider;
  • Reduce the number of services and medications that require prior authorization by regularly reviewing and eliminating requirements that are no longer warranted;
  • Increase transparency and improve communication between health insurance providers, health care professionals and patients to reduce delays in care, and ensure requests are reviewed by qualified personnel with specialty-specific credentials;
  • Provide reasons for denials in a timely and transparent way;
  • Protect the continuity of care when there are changes in coverage, health insurance providers or prior authorization requirements; and
  • Increase adoption of national electronic standards for prior authorization throughout the industry, and improve transparency around formulary decisions and coverage restrictions at the point of care.

The ACR has long criticized the practice of prior authorization, referring to it in its policy statement as a way for insurance companies to “control plan members’ access to specific pharmaceuticals and medical services.”

The ACR has released a position statement advocating for sweeping changes to the current system of prior authorization.
Source: Adobe

“There is no uniformity in the prior authorization requirements between different insurers, and the process frequently involves manually filling out multi-page forms for each patient for whom the provider has — via shared decision making with the patient — determined that a particular pharmaceutical or service is the best treatment option,” the statement reads, in part.

The group also cited a recent national survey conducted by the American Medical Association, which found that 75% of physicians felt that prior authorization can lead to patients abandoning recommended therapy. Further, 91% believed the prior authorization process delayed patients’ access to care, and 88% said the burden associated with the practice has increased in the past 5 years.


According to the ACR’s own analysis of registry data, approximately 15% of patients in a typical rheumatology practice have rheumatoid arthritis and are treated with a medication requiring prior authorization.

“For each of these patients, a rheumatologist or rheumatology professional must go through the prior authorization process at least once per year due to insurance plan requirements that continuation of therapy be renewed annually,” noted the ACR statement.

Additionally, the ACR is throwing its support behind legislation in the U.S. House of Representatives that it says would require CMS to regulate the use of prior authorization by Medicare Advantage plans, and establish a process to make real-time decisions for services that are routinely approved. It would also require plans to offer a process for electronic prior authorization, and report to CMS how extensively they use prior authorization, as well as how often they approve or deny the relevant medications and services.

The bill, called the “Improving Seniors’ Timely Access to Care Act,” is sponsored by Reps. Suzan DelBene (D-WA), Ami Bera (D-CA), Mike Kelly (R-PA) and Roger Marshall (R-KS).

“We have seen increased support for the prior authorization legislation within the U.S. House of Representatives specifically with the introduction of House Bill HR 3107, the Improving Seniors' Timely Access to Care Act of 2019,” Reddy told Healio Rheumatology. “This bill has over 200 bipartisan co-sponsors — nearly half of the House, which would be 218 members — and the support of multiple payers. Information about this bill and its sponsors are available at the Regulatory Relief Coalition website, where we have updated the co-sponsors list and the endorsing organizations list — now over 400 groups.” – by Jason Laday