Prior authorization and its impact on access to obstetric ultrasound

• Published in: American journal of obstetrics and gynecology Vol. 222; no. 4; pp. 338.e1 - 338.e5
• Main Authors: Jain, Vanita D., Bsat, Fadi A., Ruma, Michael S., Sciscione, Anthony C., Iriye, Brian K.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2020
• Subjects: Conflict of Interest; diagnostic imaging; Female; Guideline Adherence; Health Services Accessibility; Humans; Medical Overuse - prevention & control; obstetric imaging; overutilization; Practice Guidelines as Topic; Pregnancy; prior authorization; Prior Authorization - economics; Prior Authorization - ethics; Prior Authorization - legislation & jurisprudence; Prior Authorization - organization & administration; Quality of Health Care; Time Factors; Ultrasonography, Prenatal - standards; obstetric imaging; overutilization; prior authorization; diagnostic imaging
• ISSN: 0002-9378; 1097-6868
• DOI: 10.1016/j.ajog.2020.01.019

Prior authorization is a process requiring health care providers to obtain advance approval from a payer before a patient undergoes a procedure for the study to be covered. Prior authorization was introduced to decrease overutilization of ultrasound procedures. However, it has led to unanticipated consequences such as impeding access to obstetric imaging, increased administrative overhead without reimbursement, and contribution to physician frustration and burnout. Payers often use intermediary radiology benefit management companies without providing specialty-specific review in a timely manner as is requisite when practicing high-risk obstetrics. This article proposes a number of potential solutions to this problem: (1) consider alternative means to monitor overutilization; (2) create and evaluate data regarding providers in the highest utilization; (3) continue to support and grow the educational efforts of speciality societies to publish clinical guidelines; and (4) emphasize the importance of practicing evidence-based medicine. Understanding that not all health plans may be willing or able to collaborate with health care providers, we encourage physicians to advocate for policies and legislation to limit the implementation of prior authorization within their own states.