Prior Authorization

The WSMA supports physicians being reimbursed for services associated with care coordination and administrative communications with insurance companies. (Res C-6 A-23)

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)

The WSMA will advocate for state legislation, regulation and/or policy changes to reduce the total volume of prior authorization demands on physicians and other prescribers. (B-2, A-24)

The WSMA will support efforts to exempt frequently approved medical services and prescription drugs from the prior authorization process. (B-2, A-24)

The WSMA will advocate for legislation, regulation, and/or policy change to remove prior authorization and other payor-based and facility-based obstacles from evidence-based medications for addiction treatment, including but not limited to buprenorphine monoproduct and injectable medications for addiction treatment. B-12, A-24)

The WSMA supports lowering the cost of injectable medications for addiction treatment to improve access and resource stewardship. (B-12, A-24)

The WSMA supports policy that hormonal contraception, long-acting reversible contraception, and immediate postpartum long-acting reversible contraception devices should be readily available without prior authorization. (C-1, A-24)

The WSMA supports the coverage of hormonal contraception, long-acting reversible contraception, and immediate postpartum long-acting reversible contraception devices and placement by Medicaid, Medicare, and private insurers, and that these be billed and paid separately from the obstetrical global fee. (C-1, A-24)

The WSMA supports public funding for the provision of hormonal contraception, long-acting reversible contraception, and immediate postpartum long-acting reversible contraception devices at the time of service for persons irrespective of health insurance status, not limited based on income. (C-1, A-24)

The WSMA work with the legislative process to create exemptions from the prior authorization process for contracted health professionals if the plan or insurer approved or would have approved not less than 90% of the prior authorization requests in the most recent completed one-year contracted period. Furthermore, the prior authorization process would be discontinued for services, items, or supplies that are approved 95% of the time. (C-17, A-24)

The WSMA propose regulations to ensure AI denial determinations are always reviewed by a human physician to maintain accountability and patient safety. (C-17, A-24)

The WSMA establish clear criteria for peer-to-peer reviews, ensuring that only appropriately qualified and specialized physicians are allowed to act as peer reviewers. (C-17, A-24)

The WSMA advocate that the Office of the Insurance Commissioner implement a grievance and appeals process that ensures grievances involving delays, denials, or modifications of health care services are reviewed by a physician of the same or similar specialty as the physician requesting authorization for those services. (C-17, A-24)

The WSMA advocate for legislation to prevent health care service plans from retroactively denying or modifying a covered health care service based on the rescission of a prior authorization exemption, except in cases of fraud or substantial non-performance. (C-17, A-24)

Return to the WSMA Policy Compendium index

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