Q&A: Prior authorization limits, delays options in allergy, asthma care

Key takeaways:

• Most medications in allergy and asthma care require prior authorization.
• Providers should screen for failed medications at each visit.
• The AAAAI has issued policy recommendations to improve the process.

Prior authorization remains a challenge for many practices despite recent changes in regulations, with obstacles specific to asthma, allergy and immunology care.

Healio spoke with Priya J. Bansal, MD, FAAAAI, FACAAI, member of the American Academy of Allergy, Asthma & Immunology Prior Authorization Task Force, to find out more. Bansal also is a member of the Healio Asthma and Allergy Peer Perspective Board.

Healio: How does the need to get prior authorizations for treatment impact care?

Bansal: In general, prior authorizations have been shown to result in a delay of care. These delays in care lead to adverse events, including hospitalizations and worse clinical outcomes.

Healio: Does the need for prior authorization have any impact that is unique to allergy/asthma care?

Bansal: For allergy and immunology care, it is a unique situation, as most of the medications we prescribe require prior authorizations. Lately, with the favored medications for asthma picked by each insurance company, it is very difficult for physicians to find which inhaler is covered because the decision made by the insurance company is solely based upon cost, and not by what is better for the patient clinically.

For example, certain patients cannot do dry powder inhalers, but they are not given a choice for an HFA inhaler without needing a prior authorization and having to pay for the inhaler that they already know is not going to work. Another example is requiring children to use inhalers that they simply cannot use because of their age since that is the only one the insurance company allows. Families still must fill and pay for the prescription, even though the physician knows that is not the right inhaler for the child.

Healio: How does prior authorization impact the timeliness of treatment?

Bansal: Prior authorizations definitely delay therapy for patients. Some medications are able to be sampled by some physicians, but a large majority of patients do not have effective medications to help them while awaiting the authorization to go through.

Healio: How does prior authorization impact whether patients get the most effective option in treatment?

Bansal: Oftentimes, due to the hoops the physicians must jump through, the patient is not given what the physician thinks will be the most effective option. Oftentimes, they are forced to try things that are known to not work as effectively.

Healio: What are some of the biggest obstacles you see in prior authorization?

Bansal: There are not uniform guidelines with insurance companies as to what medications must have prior authorizations. Simultaneously, the insurance companies don’t have uniform guidelines — meaning that for the same medications, the requirements may be different with each insurance company.

Also, the sheer number of prior authorizations are drowning staff and physicians in administrative burden. Many times, the peer-to-peer consult is completely ineffective, as it is not done with a peer, but rather with someone in an entirely different field that does not know about allergy and immunology. Insurance companies also often reiterate that they need documentation that may have already been sent, or they come up with nontraditional requirements.

Healio: Do you have any advice that would help providers overcome these obstacles?

Bansal: First, screen patients for failed meds at each visit. Next, try to partner with an electronic medical record that may be using artificial intelligence to help the prior authorization process. Finally, try to advocate with your state society and insurance companies and support national societies to help advocate on your behalf.

Healio: At the policy level, what can be done to improve this process?

Bansal: The AAAAI Prior Authorization Task Force has issued a position statement. It recommends many things that could be done, including:

1. reduce the number of allergy and immunology specialists subject to prior authorization requirements;
2. have uniform guidelines for biologic approvals;
3. do not delay access to care for chronic or emergency medications;
4. improve transparency; and
5. have national electronic standards for prior authorization submission.

Also, we should have insurance companies consult allergy and immunology specialists make sure care is appropriate for the different ages when choosing formulary medications such as inhalers.

We can prevent insurance companies from requiring full labs and redocumentation for chronic diseases covered by another insurance carrier for years, causing a delay and denial of care because documentation is difficult to access, as well.

Healio: Do you think CMS’s Interoperability and Prior Authorization Final Rule , which digitizes the process, will help?

Bansal: It is well known that prior authorizations delay care. The new CMS ruling makes that timeline tighter and offers more transparency into denials. This is a step in the right direction, but patients need answers sooner and even further reform. I look forward to a future where this is possible for our patients.

Reference:

• AAAAI Prior Authorization Task Force. J Allergy Clin Immunol Pract. 2023;doi:10.1016/j.jaip.2023.02.014.

For more information:

Priya J. Bansal, MD, FAAAAI, FACAAI, can be reached at asthmaallergywellness@gmail.com.