Dana-Farber Cancer Institute has joined with Massachusetts hospitals, physicians, and patient advocate community in supporting reforms of insurers' prior authorization policies to reduce unnecessary delays in patient care and relieve the administrative burden in the health care system. 

Prior authorization (PA) is a cost-control process that requires health care providers to get approval from a health plan before a patient receives a service or prescription to ensure it is medically necessary and covered by the plan. In recent years, PA has proliferated to apply broadly and indiscriminately to many medical services and treatments, including generic medications. This legislation proposes a comprehensive, common-sense approach to prior authorization reforms.

WHAT THIS BILL DOES

• H1136, An Act to Improve Health Insurance Prior Authorization, and S1403, An Act Relative to Reducing Administrative Burden, would improve access and continuity of care by making a prior authorization valid for the duration of a course of treatment or at least one year, a provision that is critical for patients receiving treatment for cancer.
• The bill also requires insurers to honor the patient's prior authorization from another insurer for at least 90 days.
• The bill seeks to reduce delays in care by requiring utilization review determinations to be made within two working days and 24 hours for urgent care to ensure prompt access to care.
• The bill promotes transparency and fairness by prohibiting retrospective denials for preauthorized patients.

WHY THIS MATTERS

• A recent study by the American Medical Association showed that prior authorizations delay access to care for patients and have been shown to interfere with medically necessary treatment protocols, resulting in adverse clinical outcomes and a recent report by a state agency identified prior authorization’s growing administrative burden is contributing to provider burnout.
• Dana-Farber must obtain insurers’ prior authorizations for treatments and procedures that are already heavily regulated and meet rigorous evidence-based standards.