In February, the Centers for Medicare and Medicaid Services (CMS) finalized new federal regulations around prior authorization. As a result, health insurers will be required to make major changes to their prior authorization processes.
Prior authorizations, or optimization reviews as they are more accurately described, serve as safety and cost checks for patients.
For example, they can stop the over-prescribing of opioids, or flag that a patient is on a separate medication that has a dangerous interaction with opioids.
They also help ensure affordability. For instance, some doctors accept money or gifts from drug and medical device companies who want the doctors to prescribe their drugs and use their products. These reviews make sure patients receive the most affordable and beneficial treatments, regardless of the doctor’s financial incentives.
While these reviews are important, they can be made more efficient through new technology and transparency.
And that is what the new federal regulations intend to do.
They require insurers to create a new, electronic process for reviews. And they require that all services subject to optimization reviews are made public so doctors can easily search for them.
All-in-all these changes should make the process quicker and more seamless for patients and their doctors.
At the state level, the North Carolina General Assembly is also considering mandating changes to the prior authorization process.
Many of the changes in the state legislation are duplicative with the new federal regulations. At best, implementing these changes at the same time as the federal regulations will create confusion and overlap. At worst, it will slow things down even further for patients and providers.
We know that studies have found that optimization reviews can save lives and save families thousands in premiums.
We also know they can sometimes be a burden for patients and their doctors.
The new federal regulations will go a long way in addressing those burdens.
The North Carolina General Assembly would be wise to let these regulations happen before considering their own mandated changes.
.jpeg)
