APA Misses the Mark on Prior Authorization

Last month the American Psychiatric Association approved a position paper on prior authorization for reimbursement of costs for psychotropic medications:

 

“The American Psychiatric Association is opposed to any requirement of prior authorization for psychotropic medications prescribed by psychiatrists prior to payment by insurers, except for instances of clear outlier practices or an established evidence base which implicates concern for patient safety. In those instances, the decision to require prior authorization or documentation should be made only by a Board Certified Psychiatrist.”

 

I suspect a lot of insurance executives and medical directors enjoyed a good laugh if they bothered to read this.

 

Prior authorization usually involves the psychiatrist providing information by form or phone so the payer can decide whether to authorize reimbursement for the drug. Payers have a legitimate interest in controlling costs, as do their subscribers who must pay the premiums that fund reimbursement. Insurance is a contract between the payer and the subscriber. Payers should abide by the terms of the contract, but no contract obligates the insurer to pay for everything without question.

 

For this feel good statement to mean anything at all APA must define “outlier practices” and “concern for patient safety.” Require the decision to “be made only by a Board Certified Psychiatrist?” Easy. Give the doctor a rubber stamp.

 

The real problems with prior authorization? They waste the psychiatrist time. They often obtain only information already in their hands or obtainable from the patient or the prescription (often with the implication that they trust the physician more than their own subscriber). If they need further clinical information they should obtain it from the medical record, in many cases today potentially accessible from “the cloud” without involving the physician.

 

Reimbursement questions are not emergencies. Subscribers should demand coverage of the first month to allow time for the payer to decide whether to reimburse. They might even consider whether the drug works and the patient even likes it.

 

APA should tell its members, not payers, how to behave. Psychiatrists should stick to diagnosing and treating mental disorders instead of attempting to get money for their patients, but they should consider costs. Reimbursement is between the patient and the payer.

 

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