March 10, 2017

Alternatives to Prior Authorization Requirements

It is the American College of Radiology’s (ACR’s) position that preauthorization programs should not be permitted to hinder patient care or intrude on the practice of medicine. As a long-time supporter of the application of Appropriate Use Criteria (AUC) through Computerized Decision Support (CDS) tools as a superior means of facilitating value-based care and appropriate imaging utilization the ACR applauds NJs efforts in addressing prior authorization delays.

Use of an electronic Clinical Decision Support (CDS) tool allows imaging requests to be vetted against the evidence-based AUC at the point of care. Providers receive real-time feedback on the clinical utility of a request, and, if necessary, can be guided to either a more appropriate exam or given consideration for direct consultation with a local Radiologist. This can be a useful instrument to complement the expertise of the state’s primary providers and imaging specialists. Granting exemptions to providers utilizing AUC built-ins within CDS tools better enables the health care providers to deliver high-quality care in a timely and efficient manner.

Recognizing problems associated with prior authorization, the AMA developed Prior Authorization and Utilization Management Principles:
Principle #20: Health Plans should offer providers/practices at least one physician-driven, clinically based alternative to prior authorization, such as but not limited to "gold-card" or "preferred provider" programs or attestation of use of appropriateness use criteria, clinical decision support systems or clinical pathways.

New Jersey AB 3007


The bill requires the medical director of a carrier which offers a managed care plan or uses a utilization management system in any of its health benefits plans to ensure that no prior authorization is required by the carrier in order for a covered person to access the following health care services: physical and occupational therapy services; prescription drugs and biologics; radiological examinations; durable medical equipment; and surgical services that address a single organ or organ system.