Prior Authorization Policies in HMO Care Management

Core Components of HMO Prior Authorization Policies

The American College of Cardiology recommends that prior authorization policies should be designed to minimize administrative burdens while maintaining appropriate utilization management 1, 2
HMOs should consider streamlining overlapping requirements between prior authorization and other administrative processes to benefit both providers and payors 1
Policies should include clear timelines for authorization decisions to prevent delays that could negatively impact patient outcomes 3
HMOs should establish dedicated teams to navigate the prior authorization process, particularly for complex or time-sensitive cases 3

Prior authorization forms should require specific patient criteria including patient diagnosis and condition details, relevant clinical measurements with source documentation, previous therapies used and rationale for the requested treatment, documentation addressing known contraindications and steps to minimize risks, and evidence that delays in therapy may cause harm to the patient, as recommended by the American College of Cardiology 4

Pharmacists can play a key role in navigating insurance coverage and patient assistance programs, according to the American College of Cardiology 5
Local pharmacy resources and pharmacy professionals should be engaged to jointly address prior authorization requirements, as suggested by the American College of Cardiology 4

Prior authorization delays can limit patient access to appropriate medical interventions, potentially compromising quality of care 3
Delays in time-sensitive procedures beyond 8 weeks may negatively impact patient outcomes 3

The American College of Cardiology recommends documenting all steps taken in the patient's health record when navigating prior authorization processes 4
The American College of Cardiology suggests not hesitating to appeal decisions that are contrary to best patient care 4
Consider alternative coding systems for procedures requiring prior authorization to better account for administrative burden, as recommended by Praxis Medical Insights 3

Standard requests through patient assistance programs typically allow for 90-day supplies with 3 refills to provide coverage for 1 year, according to the American College of Cardiology 5
Income verification and reordering procedures are among the most challenging aspects of patient assistance programs, as noted by the American College of Cardiology 5

Price-checker tools can assist patients in locating retailers with lowest cost medications when prior authorization is denied, as recommended by the American College of Cardiology 5
Healthcare organizations should consider developing systems to track prior authorization outcomes and identify patterns to improve future processes, according to Praxis Medical Insights 3