Perspective: Streamlining Prior Authorization Requirements to Improve Patient Care

Medicare Advantage plans provide essential health insurance coverage for approximately 22 million Americans, or about one-third of all Medicare beneficiaries.

However, for many individuals with MA plans — and millions more who have commercial insurance — prior authorization rules can deny or slow down needed care, putting patients at unacceptable risk. 

Prior authorization is a process in which a provider, on behalf of a patient, requests approval from the patient’s insurer before delivering a treatment or service. It can be a valuable tool when used appropriately; unfortunately, many commercial health plans apply prior authorization requirements in ways that create dangerous delays in care, contribute to clinician burnout and drive up costs for the entire health care system.

The AHA is working on several fronts to address this problem.

We have signaled our strong support for bipartisan legislation — the Improving Seniors’ Timely Access to Care Act of 2021 — introduced in the Senate this week. This bill and its House companion aim to streamline prior authorization requirements under MA plans by making them simpler and uniform, applying the same rules to all by eliminating the current wide variety of prior authorization methods that frustrate both patients and providers.

We also are calling for changes on the regulatory front. Last December, the Centers for Medicare & Medicaid Services issued a proposed rule designed to standardize the prior authorization process making it easier and more efficient. 

While we support the end goal, the proposed rule did not extend its protective umbrella to MA plans, an extremely troubling omission that significantly reduces the potential impact of the regulation. 

This week, we strongly urged CMS to revise and reissue the regulations and extend the policies to MA organizations. We also urged the agency to consider additional regulations to limit care delays, and conduct oversight and enforcement for plans that have demonstrated problematic prior authorization usage in the past.

At the same time, we continue to look closely at other promising solutions, such as a new Texas law that permits physicians who have a 90% prior authorization approval rate over a six-month period on certain services to be exempted — or “gold carded” — from prior authorization requirements for those services.

And, we’re continuing to highlight for policymakers and the public, how problematic prior authorization policies put additional burden on clinicians, contribute to workforce burnout and divert resources from patient care. 

Last year, one 17-hospital system reported spending $11 million annually to comply with health plan prior authorization, and a 355-bed psychiatric facility needed 24 full-time staffers to deal with authorizations.

This kind of time, effort and resources are better spent on patient care … not paperwork. 

We will continue to fight for improvements to the prior authorization process that allow for a better care experience for patients.