New Billing Codes for Prior Authorization Work Proposed by AMA

New Billing Codes-for Prior Authorization Work Proposed by AMA

New billing codes: Medical experts might consider creating new billing codes for the time doctors and their support staff spends working on prior authorizations.

The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Board meets May 9-11 in Chicago. On the meeting’s agenda are three potential new CPT codes “for reporting services (physician, QHP, clinical staff) related to the approval of [payer] procedures” that relate to qualified health plans.

 New Billing Codes for Prior Authorizations: What does it say?

Proposals for new billing codes may come from industry, medical societies, governments, health insurance companies, hospitals, and others.AMA does not disclose the identities of applicants because their applications may contain confidential information.

But on the agenda was a file containing dozens of studies and documents that confirmed what many doctors already know: in its current form, prior authorization is a burden that delays patient care – sometimes with negative effects on the patient’s health – and At the same time, medical practices take up a lot of time. Of time and money.

Among the evidence: AMA’s own 2022 provider survey, where 94% said PA always, often, or sometimes delays access to needed care. According to the same survey, 80% of doctors said that prior authorization at least sometimes causes patients to stop their treatments.

The 2023 Medical Group Management Association survey found that 89% of physician practices had to add or redeploy staff to work in AF due to increased requests.47% said they have hired full-time equivalent employees to meet increasing prior authorization requirements.

 Gold Card Fizzle: Is There a Better Way to Streamline Prior Authorization?

Physicians, policymakers, payers, and others have wondered whether a “gold card” program for medical practices could ease the prior approval process for practices creating a registry of appropriate treatments for patients. But that hasn’t worked so well in Texas, where the Texas Medical Association

Cited figures from the Texas Department of Insurance in December 2023 that only 3% of doctors and other clinicians met licensing requirements for that state.

A New York urologist referred to this report and said the gold card had failed spectacularly in Texas.

Currently, the costs of the prior authorization process lie with patients and providers, essentially one party, creating serious inefficiencies in the market. The best solution is to solve the problem in a way that is equitable and fair to doctors, other healthcare providers, and health insurance companies, the urologist said.

“Good public and economic policy must balance costs, benefits and incentives. Currently, all costs are borne by medical practices, and all financial savings and benefits from prior authorization flow to health insurance companies, creating perverse incentives,” the urologist said in an email to Medical Economics: “Ultimately, all incentives are there Not defending patient’s name: The plan receives 100% of the unspent money as profit; Providers avoid losing money on every

Prior authorization they issue.” Denial. the duty of care or the impermissible refusal of the prior authorization provided by them.

Previous approvals have a “life of their own”:

In 2020, the then-president of the AMA Medical Economics shared his experiences with previous approvals.

When pre-approval took place, the focus was on new drugs with very high prices, where evidence was still accumulating and where there may be differences in treatment. It’s gotten to the point where, as a dermatologist, I take pre-approvals daily for generic topical like cortisone products that were invented in the 1960s. So the expansion was – and we saw this in the data – dramatic. The focus is no longer on expensive drugs that are unique or new. Atypical doctors are no longer the focus. It seems to have taken on a life of its own.

 Reasons for optimism?

The AMA president said he was optimistic because lawmakers and policymakers understood at that point that the prior approval process was out of control. The WADA President’s predictions have recently turned out to be partly reality. Known as the Improving Timely Access to Senior Care Act, the bill with provisions to streamline prior authorizations has strong bipartisan support and has passed the House of Representatives. This year, lawmakers praised the U.S. Centers for Medicare and Medicaid Services for implementing new requirements with the same goals.

 New Billing Codes for Prior Authorizations: A Double-Edged Sword for Patients and Physicians

Although the impact on patients and physicians is known, the proposed new billing codes may not be a failure. In 2022, health media reported on AMA members’ debate over resolutions advocating the development of CPT codes to reimburse physicians for time spent on prior authorizations. Some doctors supported the plan, while others argued it could undermine needed reform efforts without insurers paying doctors for the work required in their contracts.

 By the Numbers:

Appearance on the agenda does not guarantee that a new code will reach the U.S. healthcare system. As of February 2024, the AMA CPT Editorial Board agenda included 45 proposals for new additions or deletions revised into CPT codes. Of these, 26 were approved, four rejected and 16 withdrawn.

At the September 2023 meeting, there were 76 proposals; 31 were approved, 13 were rejected, 22 were withdrawn and nine were postponed. According to summaries published on the WADA website, as of May 2023, there were 61 proposals,  29 approved, five rejected, 20 withdrawn, five postponed, and two canceled.


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