Prior Authorization

The WSMA supports physicians being reimbursed for services associated with care coordination and administrative communications with insurance companies. (Res C-6 A-17)

The WSMA supports electronic approval of prescription requests. (B-14, A-20)

The WSMA support the elimination of fail-first protocols from the prior authorization process (B-14, A-20)

The WSMA support prior authorization policy requiring peer to peer review, immediate response for emergent cases, and up to 24-48 hours to reply in all other cases and if no response, then the request is approved. (B-14, A-20)

The WSMA support policy that in the case of denial of a prescription, the insurer is to provide a response to the prescribing provider, within 24-48 hours or less, via fax or HIPAA compliant email, that includes the specific reason(s) for denial of the medication, suitable alternatives to the prescriber’s preferred medication, and a simple process for requesting an appeal. (B-14, A-20)

The WSMA support policy that if there is a denial of the medication prescribed, and an appeal is initiated, the appeal be reviewed by a physician trained in the field for which the condition is being treated (Peer to Peer review) within 24-48 hours, and that an emergency fill of the prescribed medication be provided during the review period. (B-14, A-20)

That the WSMA support policy that requires insurance companies review their formularies regularly with physicians in the field to be certain there is reasonable evidence to restrict certain medication from the formularies. (B-14, A-20)

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Abbreviations for House of Delegates report origination:

EC – Executive Committee; BT – Board of Trustees; CPA – Council on Professional Affairs; JC – Judicial Council; CHS – Community and Health Services