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BlueCross BlueShield of WNY drops preapproval on some services

BlueCross BlueShield of Western New York today announced it will lift the prior authorization requirement for 212 services, meaning doctors and patients will no longer need the insurer's approval in those cases.

The news will please many physicians who often complain that prior authorization policies, put in place to reduce unnecessary care and control health care costs, can be a time-consuming headache that complicate medical decisions.

The change is consistent with a call last month by 17 health care organizations, including the American Medical Association, for reform of prior authorization requirements imposed by health plans for medical tests, procedures, devices and drugs. About 75 percent of 1,000 doctors surveyed by the AMA responded that preauthorization for services constituted a "high" or "extremely high" burden to their practices.

Preauthorization is the process used by health insurance companies to determine if a prescribed procedure, service or medication is medically necessary and covered under a member’s benefits. BlueCross BlueShield said only 3 percent of all its medical claims in 2016 were subjected to prior authorization.

"In many instances, we realized that prior authorization was adding costs and time that didn't help. Doctors felt as though they were running a gauntlet to get approval," said Kyle Rogers, manager of corporate relations.

Other major insurers in the region, such as Independent Health and Univera Healthcare, say they also review prior authorization and will eliminate requirements that no longer add value, a shift getting more attention as payments to doctors nationwide move from fee-for-service to a more value-based system. But a block of 200-plus diagnostic codes at one time is big -- more than 10 percent of the insurer's preauthorization requirements, according to Blue Cross Blue Shield.

The services chosen for elimination of prior approval fall under 20 categories of care -- mainly for primary care physicians -- such as physical therapy or skilled nursing services for home health care. The policy also affects power wheelchairs under medical equipment.

After a review of data, the insurer found that some prior authorizations no longer made sense based on changes in medical care or were approved so often that the requirement made little sense.

"In some instances, these were legacy medical policies embedded in our health plans that were put in place for the right reasons but, with changes over time in the state of the art in medicine, now need to get out of the way. They just cost extra time and are not worth it," said Julie Snyder, vice president of corporate relations.

BlueCross BlueShield officials said its clinical practice guidelines will remain in place for services.

“Today’s announcement puts our physicians more squarely in the driver’s seat regarding medical decision making and the care they provide to our members," Dr. Thomas Schenk, senior vice president and chief medical officer, said in a statement.

BlueCross Blue Shield officials said they are considering lifting preauthorization for additional services in the future. The current change applies to the company's commercial and Medicare lines of business.

The American Medical Association in its policy recommendations said prior authorization could be improved by more consistent application of a handful of principles, including whether the requirement had clinical validity, maintained continuity of care, and didn't significantly impede timely access to care and administrative efficiency.

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