Patients Over Prior Auth FAQ

What is the current status of prior authorization in Indiana? 
All payors require prior authorization for various procedures, services and medications. Current Indiana law requires that prior authorizations be completed within a 48-hour limit for urgent care and a five-business day limit for other requests. But that’s not always timely enough. In 2023, the Indiana General Assembly passed a bill exempting 49 commonly used CPT codes from prior authorization in the state employee health plan, but that is a very small subset of all Hoosiers. In January 2024, the Centers for Medicare and Medicaid Services announced requirements of 72 hours for expedited requests and seven calendar days for other requests unless state laws require a shorter time frame, as existing Indiana law does. 

Why is ISMA collecting prior authorization stories? 
Indiana is one of the unhealthiest states in the country, and patients need care. Indiana’s average denial rate for in-network claims by healthcare.gov (marketplace) issuers in 2021 was 23.6% -- the third highest in the country. Some of those denials are due to prior authorization. By gathering the stories from our thousands of physician members, their staff, and their patients, we can identify ways to improve patient outcomes by reducing interference in health care delivery. The public, policymakers, regulators and payors need greater awareness of how much prior authorization is interfering with patient care.

What kind of information is ISMA looking for?
ISMA invites physicians and others to share de-identified, specific examples of prior authorization interfering with patient care and the impact of that interference, such as wasted administrative time, increased patient acuity, adverse patient outcomes, and added health care costs. ISMA also invites suggestions of how to improve the process.  

Why ask about the type of insurance and payor?
Different health plans fall under different sets of laws and rules. For that reason, legislative solutions often need to be targeted by insurance type. But legislation is not always necessary or the answer.  In fact, some health plans and health plan conduct fall outside of state insurance laws altogether. By identifying the type of insurance and payor, ISMA can work on targeted solutions, which includes working collaboratively with payors on solutions.  

How do I share my story?
ISMA has set up an easy to use, succinct form where physicians and others can submit de-identified stories and suggestions. This link may be shared with nonmember physicians, physician staff, and patients/caregivers.

How will these stories be shared?
ISMA will share prior authorization stories with payors, legislators, regulators, and the public to increase awareness of the problem and to help find ways to improve the prior authorization process for all. ISMA will also share the stories with other ISMA members through ISMA publications. ISMA will only share submitter names with the submitter’s permission.

Why does the form ask for the submitter’s name?
There may be opportunities to share individual names of physicians with legislators if the physician lives in that legislator’s district and the physician’s story helps illustrate the problems with prior authorization or a possible solution. This can also be a simple, non-adversarial and unintimidating way for physicians to make connections with their legislators – by telling stories about their patients. Legislators routinely tell ISMA staff that key elements of effective advocacy are personal interactions and mutual relationships.

How will we know if progress is being made?  
ISMA will publish updates about this initiative, including stories submitted, advocacy efforts and results. That is why it is important that physicians continue to send new stories for us to share to keep the attention on this issue.