Addressing Administrative Burden, Patient Access Through Prior Authorization Reform

Mandated, payer-directed prior authorization for diagnostic imaging, therapeutic procedures and medications is a great barrier to patient access in today's cardiovascular practice landscape. The ACC is committed to driving prior authorization reform to improve patient care and reduce administrative burden.

The ACC, in collaboration with ACC State Chapters, is advocating for clear and standardized transparency rules, prior authorization approval and denial data sharing, and Gold Card programs which would exempt high performers from certain prior authorization requirements, at both the federal and state level. The popularity of legislation aimed at reducing administrative burden by reforming health plans' step therapy protocols and prior authorization policies continues to grow.

The College remains committed to engaging with health care payers, expressing opposition to laborious prior authorization requirements, and ensuring they and their prior authorization vendors are utilizing ACC's practice guidelines, appropriate use criteria and standards of practice within their coverage policies and criteria.

Most cardiovascular prior authorization requests are processed by the following vendors:

Principles For Prior Authorization Reform

Building from a list of goals developed by an American Medical Association-led coalition, the ACC supports the following principles centered around transparency, standardization and efficiency:

  1. Define "selective application of prior authorization" to mean review and authorization for coverage of a test or treatment where appropriate for requests not covered by Appropriate Use Criteria (AUC) or guidelines. Prohibit procedure and medication substituting by payers consistent with AUC and guidelines.
  2. Allow for "prior authorization program review and volume adjustment," so payers and contracted benefit managers can authorize requests for tests and treatments from providers or practices that demonstrate compliance with established AUC and guidelines.
  3. Require payers to make rates of allowed and denied procedures available to consumers.
  4. Avoid interruption in care by allowing patients granted coverage for a given treatment under one payer to transfer that coverage to another payer.
  5. Establish online standardized prior authorization tools and criteria for providers and their practice staff.