NCQA Weighs In On Prior Authorization

The case that has put Aetna’s prior authorization denials process under a microscope also raises the question of how such issues are policed by outside entities. According to reports, at least four states are investigating this particular case, and two Democrats in the US Senate have asked for details about the insurer’s review process. 

The National Committee for Quality Assurance (NCQA), is also investigating. For that reason, NCQA president Margaret O’Kane could not comment on this specific case. But she did address how the process should work in general in order to comply with NCQA standards. 

When it comes to a denial, “we require that the final decision be made by a physician,” said Ms O’Kane. When a patient does not comply with certain requirements, such as completing a necessary test, she explained that NCQA “would not expect to have the whole medical record opened up again,” but that “there should be a medical record review at some point in the process. This is what our surveyors look for [when assessing a payer’s processes] using a random sample of denials.” 

She added that utilization management nurses “can facilitate the decision-making process by summarizing information. There is nothing inappropriate about that.” Additionally, if the decision is in a specialized area, payers “have to have a [specialist] brought into the process.” 

Ms O’Kane noted that not all plans are perfect—which is the reason for outside scrutiny and certification. “When a plan doesn’t pass, we allow for corrective action plans. This is why you need honest third parties looking at and validating that these kinds of delicate decisions are being handled appropriately.” 

—Dean Celia

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