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