What Every Provider Should Know About Clinical Guidelines and Prior Authorization
Clinical guidelines are developed by subject matter experts to advise healthcare professionals about the most appropriate care for a wide variety of specific patient scenarios, such as new lower back pain, headache, preventive care, or cancer. The guidelines provide support to help providers continue to practice evidence-based medicine in an ever-faster innovation environment, and are also an important tool in the prior authorization process to help to improve patient outcomes.
Understanding how clinical guidelines are used during the authorization process can help providers to avoid unnecessary peer-to-peer calls, denials, and appeals.
A Brief History of Clinical Guidelines
In some form, clinical guidelines have been a fundamental component of the practice of medicine since healers first discussed how best to engage patients. The first known formal clinical guidelines may have been written by Hippocrates. Credited with advancing the systematic study of clinical medicine, he summed up medical knowledge and prescribing practices for physicians in the Hippocratic Corpus, works written for both specialists and lay people, sometimes from opposing viewpoints. This library of medical texts written between the sixth and fourth centuries Before the Common Era probably contained the earliest clinical guidelines.
The modern age of clinical guidelines began with a 1992 Institute of Medicine (IOM) report, which defined guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances." Today numerous guidelines are produced by specialty professional organizations—such as the American College of Cardiology or National Comprehensive Cancer Network, as well as by governmental bodies such as the Agency for Healthcare Research and Quality.
How Clinical Guidelines Are Developed
The initial development of guidelines typically includes the following steps:
Step One: Identify and delineate the subject area (e.g., cancer, back pain)
Many guidelines are conveniently organized by body location, known or suspected disease, and symptoms, and are structured exactly as providers are trained to think.
Step Two: Convene and lead a guideline development group of subject matter experts
The individuals appointed to create—or update—clinical guidelines may include:
- Healthcare professionals
This collaborative approach to clinical guideline development ensures that best practices from a variety of settings and viewpoints are incorporated to produce the best outcomes for patients. All participants must have specific knowledge of the clinical domain; the time, resources, and skills to scrutinize evidence; and the capability to make objective value judgments based on their expertise, clinical studies on the subject matter, and analysis of the medical evidence available to them. Group members must also be free of conflicts of interest, and are required to declare all interests and activities resulting in any potential conflicts of interest by written disclosure.
Step Three: Evaluate available evidence about the clinical question or condition, and assess the strength and quality of each individual publication using a validated approach
It is important to have a rigorous process of accumulating and assessing the best available evidence, resulting in the most current and authoritative guidelines. The guidelines are developed in accordance with the standards of accreditation agencies (URAC and NCQA), state and federal laws, and Center for Medicare & Medicaid Services (CMS) requirements. The guidelines are based on criteria from medical societies like the American College of Cardiology and the American College of Radiology. Scientific evidence from recently published, peer-reviewed medical literature is also used to compile the guidelines. Practicing community physicians and subject matter experts at leading academic institutions also contribute to the formation of the clinical guidelines.
Step Four: Translate evidence into structured recommendations that are clear and easy to apply in clinical practice settings
According to the Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines, for each recommendation, the following should be provided:
- A clear explanation of the reasoning
- A description of potential benefits and harms
- A summary of relevant available evidence (and gaps), as well as of the quality, quantity, and consistency of the evidence
- A rating of the level of confidence in the evidence underpinning the recommendation. Every set of clinical guidelines should also include information on the cost implications of alternative, preventative, diagnostic, and management strategies for each clinical situation.
- A rating of the strength of the recommendation by utilizing a scale such as the one developed by the American Academy of Family Physicians
- A description and analysis around any differing opinions regarding the recommendation
- A discussion of values, opinion, theory, and clinical experience informing the recommendation.
- Clinical guidelines must be updated as new research emerges so they do not lose their clinical relevance.
Clinical Guidelines and Prior Authorization
Clinical guidelines are key to making the process of obtaining prior authorization easier and more efficient for clinicians and administrators. Guidelines can be a very concise reference that providers can access while in the process of seeing patients. While it is unlikely that you will need to look at guidelines with every requested imaging study, for example, it is comforting to know they are available in cases of uncertainty. Additionally, physicians and other clinician reviewers apply the same clinical guidelines to evaluate the medical necessity of a specific health care service during prior authorization requests. Understanding the evidence-based guidelines relevant to a specific prior authorization request can increase the likelihood of an easy path through the process.
In summary, clinical guidelines are structured, robust evidence-based documents that are created to support physicians and other health care providers by enhancing their ability to provide the most evidence-supported care for each patient they serve.