State & Federal Legislation For Prior Authorization: How Can Health Plans Prepare For The Regulatory Tidal Wave

Summary of State & Federal Legislation White Paper:

Everyone agrees that utilization management, more specifically prior authorization, is ripe for innovation. Seeking to expedite necessary change, federal and state government bodies are proposing and enacting new regulations to speed and standardize the prior authorization process. Some of these rules are positive steps towards increasing transparency and expediting the process to reduce patient delays. However, other mandates—such as a rule that would essentially eliminate PA for many services by “gold carding” providers who meet certain approval thresholds—have the potential to increase PA complexity, effectively hindering one of a health plan’s most important tools for impacting value and quality.

We review the most significant proposed and enacted regulations, including mandates such as gold carding, and their potential impact on health plans. We also discuss how plans can leverage innovative technology to comply with these regulations and seize upon the opportunity to improve outcomes and reduce costs through better provider and patient collaboration.