Utilization Review and Pre-Authorization

A UR/UM makes sure treatments prescribed are spot on, not excessive and aligned with latest medical guidelines.

By Carla Rodriguez | Jan. 19, 2024 | 5 min. read

Utilization Review and Utilization Management can be used interchangeably. These terms refer to the process of experts working for insurance companies reviewing the prescribed medical treatments. It is a way to ensure patients’ are following best practice guidelines and getting the right care without unnecessary extras.

This is why Utilization Management comes into play when discussing opioid prescriptions. Before opioids are given to the patient they must go through a prior authorization process through the insurance company. When handling substances with such a high risk for misuse and dependence there needs to be controls in place. A UR/UM makes sure treatments prescribed are spot on, not excessive, and aligned with the latest medical guidelines.

 

How Long Does Prior Authorization Take?

Prior authorization is an insurance process where carriers evaluate and approve certain medical treatments, before giving the green light to the insured patient. No prior authorization, no coverage – it’s that simple.

The primary purpose is to confirm the services being requested are medically necessary and cost-effective. Insurance companies can also identify potential fraud or abuse of medications by reviewing service requests. This is a way of protecting the healthcare system and the policyholders.

Prior authorization may take days or weeks depending on the request. Prior authorization specialists are required to study and inspect medications and treatments that may seem excessive to the general public but are necessary in the long run. According to a study conducted by, the John Hopkins Bloomberg School of Medicine, “After adjustment, prescriptions subject to prior authorization were associated with 0.33 fewer overdoses per 1000 prescriptions.

 

What States Require Utilization Review?

States use utilization management policies to ensure the delivery of appropriate care, but also to address other goals, such as reducing the potential for fraud, waste, and abuse and controlling program costs. Utilization management policies are used for a variety of medications and services but today we will be looking at their effect on opioid prescription and Medication- Assisted Treatment (MAT). The reason for these policies to be more stringent is the concern for abuse of controlled substances.

MAT refers to the combination of medications and counseling to treat substance abuse disorders. Prior authorization requirements can interrupt the accessibility of treatments for opioid dependency to individuals who need it the most. In these situations, utilization management-mandated states have changed their policies and reduced barriers to accessing MAT.

Here is a list of states that require Utilization Review:

  1. Arkansas
  2. California
  3. Florida
  4. Kentucky
  5. Massachusetts
  6. Mississippi
  7. Montana
  8. North Dakota
  9. Tennessee
  10. Texas
  11.  Utah
  12. Wyoming

 

Drug Utilization Review

Opioid overuse is a significant public health concern. Utilization review helps prevent the overutilization of opioids, mitigating the risk of dependence, addiction, and other associated complications. It promotes responsible and targeted use of these powerful medications.
Many times, utilization management will intervene when opioids are prescribed and require the doctors to provide weaning plans, reduce the prescription, and other preventative measures.

In a study published by the American Journal of Managed Care, they found that prior authorization was associated with a decreased likelihood of subsequent overdose in adjusted models. These studies need further work to discover the mechanisms for this association, but it is a step in the right direction.

  • Another concern around Opioid User Disorders (OUD) is the availability of Medication Assisted Treatment (MAT). MAT has proven effective in the treatment of opioid use disorders and the objective now is to make it available for those who need it most.
  • Prior authorization requirements are the leading complaints from physicians due to response times. PA responses can occur the same day as requested or take up to 14 days, delaying treatment for vulnerable patients.
  • The good news is that the number of states requiring prior authorization for MAT medications decreased from 48 in 2011–2013 to 30 in 2018.

It is believed that the reason for harsh rules surrounding OUD treatments is that unlike other chronic illnesses substance use disorders are widely stigmatized, even by healthcare professionals, which can affect a provider’s willingness to offer MAT. Unlike other chronic illnesses, SUDs are widely stigmatized, which can affect provider willingness to offer MAT.

Additionally, an increased number of states have prohibited prior authorization laws regarding MOUD (medication for opioid use disorder). Eliminating the hoops physicians have to jump through to get their patients medication for opioid use disorder, can expand access to life-saving treatments.

 

Phases of DUR

A specialized subsection of utilization management is DUR, which consists of a two-phase process consisting of prospective and retrospective screening and monitoring of prescription drug claims.

Prospective reviews must incorporate point-of-sale reviews, drug counseling, and profiling patients’ current drug regimens.
Retrospective monitoring includes but is not limited to, using predetermined standards to monitor several prescribing practices, such as incorrect drug dosage, clinical misuse, therapeutic duplication, and therapeutic appropriateness of a drug. Retrospective reviews happen after the fact, meaning after the treatment or medication has been prescribed it’s determined if the insurance company covers it.

 

Every Step Counts

Utilization Review (UR) or Utilization Management (UM) serves as the gatekeeper, ensuring that medical treatments, especially in the case of opioid prescriptions, align with best practices and standards. Prior Authorization (PA) acts as a crucial checkpoint, determining the necessity and appropriateness of services before they get the green light. The duration of PA can vary, but its significance lies in upholding patient safety, preventing overuse, and complying with medical guidelines. States mandating Utilization Review for opioid prescriptions underscore the importance of responsible practices and aim to curb substance misuse.

The evolving landscape includes changes in Medication-Assisted Treatment (MAT) accessibility, with an increasing number of states eliminating prior authorization barriers, paving the way for more effective and timely interventions. Drug Utilization Review (DUR) further refines the process through prescription drug claims in a two-phase approach, ensuring both prospective and retrospective. As healthcare professionals navigate these processes, the overarching goal remains to strike a balance between providing effective treatments and safeguarding patients from potential risks and misuse.

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