The Medicaid and CHIP Payment Access Commission (MACPAC) analyzed prior authorization in Medicaid to assess for cost avoidance and barriers to beneficiaries accessing services. The brief reports that 69% of physicians surveyed indicated, “… prior authorization requirements led to ineffective initial treatments, and 68 [%] reported that prior authorization requirements led to additional office visits.”

The authors highlight the increased burden both on beneficiaries and providers. This burden is often exacerbated when payers make updates to prior authorization policy without notification to participating providers. In these instances, a provider may prepare a request for prior authorization for a service that has been transitioned to a standard covered service, while the inverse also promises problems.

Without current federal regulations requiring the collection or reporting of prior authorization requests, approvals, and denials there is very limited and inconsistent data though there does seem to be significant disparity between services, plans, ethnic populations, and geographies experiencing high rates of prior authorization and rejection.

There are no policy recommendations, though there is an expressed belief that changes imposed by the Final CMS Interoperability and Prior Authorization Final Rule may offer useful data and reporting.

The full report is available here.