Docs of the Month: Prior Authorization Under the Spotlight

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In this month’s spotlight from Pathways’ Document Depot, an HHS Inspector General audit of prior authorization practices by Medicare Advantage insurers. The OIG report was touted by lawmakers championing device-industry supported prior authorization reforms.

Docs of the Month is a regular column highlighting key findings from Pathways’ Document Depot, a database of global medtech regulatory and policy official documents, including rules, guidance documents, memos, white papers, and more from national authorities, non-governmental groups, and global organizations.

A medical device’s path from design to use in direct patient care winds through an array of checkpoints. One of the last gates to get through in many cases is prior authorization.

Prior authorization is a mechanism insurers employ to pre-review before delivery whether a health item or service should be covered for a particular patient. Requiring clinicians to seek pre-approval for a treatment or diagnostic plan can reduce healthcare spending waste and help ensure patients don’t receive inappropriate care. But physicians complain that prior authorization too often delays or outright blocks needed care, and disrupts clinicians’ ability to respond to the individual needs of patients. As the American Medical Association argues, prior authorization is “overused, costly, inefficient, opaque and responsible for patient care delays.”


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