The Ohio State Medical  Association in partnership with the House of Medicine in Ohio (state specialty societies and local regional medical societies) requests input from medical practices across Ohio regarding prior authorization (PA).
 
The goal of this survey is to assess experiences with payers since the passage of SB 129, legislation aimed at improving and streamlining the (PA) process.  This data will be used to advocate for better enforcement of current laws and to identify gaps that still need to be addressed.
 
We need your practice to respond in order to have a comprehensive view of activity across the state.
  • Please complete one (1) survey per practice.
  • The individual in your practice who is mostly responsible for interactions with payers regarding prior authorization should answer the survey.
  • The survey shall take about 10-15 minutes to complete.  Please keep in mind that your answers will not be saved until you click "DONE" at the end of the survey.  Once you click "DONE" you cannot modify your answers.
  • Although we would prefer you answer all questions, this survey does not require an answer for each question.  If a question is not applicable to you or you can't answer it, you can simply advance to the next question and click on it to continue completing the survey.
  • Only aggregated data will be used in our reporting (you are never individually identified in our analysis).
  • You will receive a copy of the survey results in January once we have completed our analysis.

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* 1. In general, would you say that it has been getting easier to get prior authorization for necessary procedures and tests over the past year or two, harder to get prior authorization or really no change over the past few years?

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* 2. In general would you say that it has been getting easier to get prior authorization for necessary medications over the past year or two, harder to get prior authorization or really no change over the past few years?

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* 3. In the last week, how long did you and your staff need to wait for an individual response to a typical PA request for procedures or tests from health plans on average?

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* 4. In the last week, how long did you and your staff need to wait for an individual response to a typical PA request for medications from health plans on average?

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* 5. In a typical week, approximately how much total staff time (in hours) would you say your practice dedicates to the PA process?

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* 6. For those patients whose treatments require PA, what is your perception of the overall impact of this process on patient clinical outcomes?

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* 7. For those patients whose treatment regime requires PA, how often does this process result in the following:

  Always Often Sometimes Rarely Never Not sure
Delayed access to care
Patient non-adherence
Therapeutic failure and unresolved health status
An adverse patient outcome
An acute episode or hospitalization

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* 8. How often are PAs denied by insurance companies?

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* 9. How often is a PA denied because of incorrect CPT or related coding issues?

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* 10. When an initial PA is determined to be incomplete, how often is the PA approved after you provide further information?

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* 11. In cases when an initial PA is denied, rank the following answer choices in order of preference (1 being your most preferred answer, all the way to 4)

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* 12. Which of the following insurers do you or your employer currently accept? (Please check all that apply)

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* 13. Which of the following Medicaid Managed Care plans do you or your employer currently accept?  (Please check all that apply)

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* 14. Prior Authorization Reforms SB 129: Awareness/General Reaction
The Ohio State Legislature passed various reforms to the prior authorization system in 2016.

How familiar are you with the legislation that was passed and the changes to PA that were mandated by this legislation (SB 129)?

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* 15. If VERY / SOMEWHAT FAMILIAR, would you say that these reforms to prior authorization have had a positive, negative or no impact on PA in your practice?

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* 16. Compliance with SB 129

The following questions will ask if you have experienced compliance with the requirements from these laws from payers.  Payers are expected to be in full compliance; as the law was passed in 2016, most provisions were in effect in January 2017 and the remainder in January 2018.

If you give examples in the questions below, please try to be specific, but to the point, in your comments.  We are trying to find concrete examples of ways you believe payers might be using work-arounds or technicalities to avoid compliance, if you feel they are technically following the law but are still finding ways to avoid complying with the requirements.  Examples of patients experiencing unnecessary delays, or adverse events, as a result of non-compliance would be of particular interest.

Insurers must disclose all PA rules to participating providers, including specific information or documentation that a provider must submit in order for the PA request to be considered complete.  

Are any of the following payers NOT complying with this provision?  (Please check all that apply)

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* 17. Insurers must disclose to all participating physicians all new prior authorization requirements at least 30 days prior to the effective date of the new requirement.  

Are any of the following payers not complying with this provision? (Please check all that apply)

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* 18. Enrollees of the health plan must receive basic information about which drugs and services will require prior authorization.

Are any of the following payers not complying with this provision? (Please check all that apply)

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* 19. A provision prohibiting retroactive denials when, on the date the physician renders the prior approved service: 
a) the patient is eligible,
b) the patient's condition hasn't changed, and
c) the provider submits an accurate claim that matches the information submitted by the provider in the approved PA request.

Are any of the following payers not complying with this provision? (Please check all that apply)

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* 20. In regards to this provision (in Q19), please describe reasons you have been given by plans for denials, now that they can no longer use medical necessity as a reason?

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* 21. A provision allowing a retrospective review of a claim where a PA was required but not obtained when the service in question meets all of the following:
  • The service is related to another service for which a PA has already been obtained and has already been performed;
  • The service was not known to be needed at the time the original prior authorized service was performed;
  • The need for a new service was revealed at the time the original authorized service was performed.
Are any of the following payers not complying with this provision? (Please check all that apply)

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* 22. Insurers must allow for a 12-month PA for medications to treat a chronic disease under certain circumstances.

Are any of the following payers not complying with this provision? (Please check all that apply)

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* 23. In regards to this same provision, in general, how frequently are you seeing PAs for drugs or conditions with 12-month approval (thinking about cases where these would be appropriate)?

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* 24. If on Q23 you answered NEVER - skip this question.

Which drugs or medical conditions are you seeing PAs being approved for 12 months?

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* 25. If on Q23 you answered NEVER - skip this question.

Are there any particular drugs or medical conditions where you are concerned about PA denials for a 12-month request?

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* 26. Web-Based System:  Insurers must have a web-based system through which to receive prior authorization (PA) requests:
  • for prescription benefits, the system shall accept and respond to PA requests through a secure electronic transmission using NCPDP SCRIPT standard ePA transactions.
  • For medical benefits, the system shall accept and respond to PA requests through a secure electronic transmission using standards established by the Council of Affordable Quality Health (CAQH) for information exchange.
Are any of the following payers not complying with this provision? (Please check all that apply)

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* 27. In regards to the web-based system requirements specifically, the following is a list of some issues that have been reported to OSMA about these web-based systems from physicians.

Would you say that each is a very significant barrier, somewhat significant, or not significant in your ability to efficiently submit PAs from your practice.

  Very significant barrier Somewhat significant Not significant N/A
Each plan has a different system
These systems are not user-friendly
There are problems with uploading information
System has timed-out or required to re-enter login/password
Still required to send information by mail
Still required to send information by fax

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* 28. Faster turnaround times for a PA request:  

  • For urgent situations, the insurer shall approve or deny the PA request within 48 hours.  (Urgent situations are those where a delay in patient care could seriously jeopardize the life, health or safety of a patient or, in the opinion of the practitioner with knowledge of the patient's condition, a delay would subject the patient to adverse health consequences without the care that is subject of the request).
  • For non-urgent situations, the insurer shall approve or deny the PA request within ten calendar days.

Are any of the following payers not complying with this provision?  (Check all that apply)

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* 29. In regards to this same provision,

In general, how often are the plans complying with the requirement that an urgent PA request be approved or denied within 48 hours?

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* 30. In regards to this same provision,

How often are plans denying request for urgent PAs (thinking about the urgent cases you see where this is appropriate)?

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* 31. If on Q30 you answered NEVER, skip this question.

What reasons are being given by plans for denying  urgent PA requests?

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* 32. Thinking about the requirement for a response within 10 days for non-urgent requests:

In general, how often are you seeing plans reply with an approval or denial in a reasonable time frame (that does not add unnecessary delays to patient care)?

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* 33. How often are you seeing plans wait until the last minute (day 10) to issue a denial?

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* 34. Some physicians have reported seeing adverse consequences, interruptions in patient care or patients abandoning their treatment course because of these delays.  Please comment in the space provided if you have had any similar experiences.

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* 35. More clarity when an insurer responds to a PA request:
  • The insurer must provide an electronic receipt to the provider acknowledging that the PA request was received;
  • If the PA is denied, the insurer must provide the specific reason for the denial;
  • If the PA request is incomplete, the insurer shall indicate the specific additional information that is required to process the request.
Are any of the following payers not complying with this provision?  (Check all that apply)

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* 36. Faster turnaround times for PA appeals:
  • For urgent care services, appeals must be considered within 48 hours after the insurer receives the appeal;
  • For non-urgent services, appeals must be considered within 10 calendar days after the insurer receives the appeal;
  • All appeals shall be between the health care provider requesting the service and a "clinical peer" within the insurer's internal utilization review operation.  A clinical peer is a provider in the same, or similar, specialty that typically manages the medical condition under review.
  • If the internal appeal does not resolve the disagreement, either the patient or an authorized representative may request an external appeal, which is decided by a neutral, independent medical expert not associated with the insurer.
Are any of the following payers not complying with this provision?  (Check all that apply)

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* 37. In regards to this same provision,

How often are the plans complying with the requirement that they reply to the appeal for urgent cases within 48 hours?

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* 38. How often are the plans complying with the requirement that they reply to the appeal for non-urgent cases within 10 days?

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* 39. How often are you able to reschedule an appeal conversation with a "clinical peer" in a convenient manner?

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* 40. How would you describe your experiences with the "clinical peer" aspect of this provision?  Please share your comments so that we can better understand how well plans are complying with this aspect of the process.

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* 41. Profile:  The following questions are used for statistical purposes only, and are never identified with your practice or with your answers individually:

Does your practice employ a coder or use a coding service?

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* 42. Is the person primarily filling out this survey:

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* 43. Please indicate the type of practice where you work.

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* 44. Practice size

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* 45. Which best describes your practice?

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* 46. Which of these best describes your practice's specialty or specialties? (Please check all that apply)

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* 47. In what part/area of Ohio do you mostly practice?

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* 48. If OSMA needs physicians to provide testimony or support to the Department of Insurance, do we have permission to contact you?  If so, please put your name and the appropriate email address and contact phone number in the space provided.  If not, just leave the space blank or indicate "no".

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