About 50 insurers signed an AHIP and Blue Cross Blue Shield Association commitment to standardize electronic prior authorization for several medical services including orthopedics.
Five things to know:
1. The standardized approach will be used for services commonly subject to prior authorization including orthopedic surgeries and imaging services, according to an April 24 news release. Standards don’t affect individual plans’ clinical policies or coverage determinations.
2. This move targets a common pain point for orthopedic surgeons. Prior authorizations have affected many aspects of orthopedics from reimbursement to scheduling and administrative strain.
“Prior authorization has seemingly prioritized standardized rules and checklists over personalized care and patient-centered decision-making,” Alex Vaccaro, MD, PhD, president of Philadelphia-based Rothman Orthopaedics, told Becker’s.
3. Recent studies also found prior authorizations didn’t reduce costs for adult degenerative spine disease patients nor primary hip replacement patients.
4. Widespread adoption is expected in 2027, and plans will launch on a rolling basis. The industry is gauging feedback from providers and medtech vendors for data requirements.
5. Participating plans include Centene, The Cigna Group, Highmark and multiple Blue Cross and Blue Shield divisions.
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