Prior Authorization Plagues Us All

If there’s one issue that unifies all physicians—regardless of specialty, practice size, or employment status—it is their mutual loathing of prior authorizations. According to a 2021 survey from the American Medical Association, physicians complete an average of 41 prior authorizations per week, an administrative burden that consumes nearly two business days of physician and staff time. The burden has become so acute that 40% of physician survey respondents hired staff to work exclusively on prior authorization requirements.

Getting authorized to provide services demands time and attention that would be better spent on patients and their care. After-hours navigation of ever-changing, non-reimbursable criteria only adds to the frustration. Physicians and staff are driven to madness by red tape while patients suffer potentially health-threatening delays in receiving approval for necessary treatment, even if—and that’s a big “if”—at the end of a long and often arbitrary process the procedure or prescription is approved.?

Prior authorization undermines physicians’ medical expertise and leads to considerable delays in patient care. According to that same AMA survey, 93% of physicians reported care delays associated with prior authorization, and 82% said these requirements can at least sometimes lead to patients abandoning treatment. Failure to administer medically necessary care can lead to poor health care outcomes. Most startlingly, 34% of AMA survey participants reported that prior authorization led to a serious adverse event, such as hospitalization, disability, and permanent bodily damage or death, for a patient in their care.

On a macro level, because physician practices need to hire staff to work exclusively on prior authorizations, and with delays caused by the process sometimes leading to serious adverse events requiring higher levels of care, prior authorizations increase the cost of delivering care for everyone.

The WSMA has worked hard to address prior authorization challenges in Washington. You may recall that new rules went into effect in 2018 that were intended to ease the administrative burden you face as you strive to meet the requirements of state-regulated insurers or their third-party administrators when seeking prior authorization of medical services.

The rules set specific timelines and communication requirements and are summarized here. You’ll also find guidance on 2015 rules covering prior authorization of prescription drugs.

If you encounter an insurer or third-party administrator out of compliance with Office of the Insurance Commissioner’s prior authorization requirements, you can easily file a complaint by utilizing the WSMA’s Prior Authorization Navigator’s complaint form. We urge you to take advantage of this tool.

At the federal level, Congress is increasingly concerned about the negative impact of prior authorization on patients and physicians within federal health care programs. In fact, just this week a federal report found that some people enrolled in private Medicare Advantage plans were denied necessary care. Helpfully, a bipartisan collection of House and Senate lawmakers have introduced H.R. 3173/S. 3018, the Improving Seniors’ Timely Access to Care Act. The bill is sponsored by Washington’s CD 1 Rep. Suzan DelBene, with other co-signers from our state including Reps. Schrier (CD 8), Smith (CD 9), Strickland (CD 10), Herrera-Beutler (CD 3), and Larsen (CD 2).

The bill reduces unnecessary delays in care by streamlining and standardizing prior authorization under the Medicare Advantage program. Specifically, the bill would:

• Require Medicare Advantage plans to implement electronic prior authorization programs that adhere to newly developed federal standards and are capable of seamlessly integrating into electronic health systems (vs. proprietary health plan portals), as well as establish real-time decision-making processes for items and services that are routinely approved.
• Mandate that plans report to the Centers for Medicare & Medicaid Services on the extent of their use of prior authorization and the rate of approvals and denials.
• Require plans to adopt transparent prior authorization programs that are reviewed annually, adhere to evidence-based guidelines, permit gold carding, and include continuity of care for individuals transitioning between coverage policies to minimize any care disruptions.
• Hold plans accountable for making timely prior authorization determinations and providing rationales for denial.

While the legislation would only apply to Medicare Advantage plans, it represents a major first step at the federal level toward combatting insurer oversteps. The WSMA continues to meet with our members of Congress urging a vote on the bill this calendar year.

While we wait to see what action Congress will take, the WSMA continues to work on the issue in our state. Based on the WSMA’s recent advocacy, plans in Washington are required to provide data on their prior authorization practices to the Office of the Insurance Commissioner. Data points include those medical/surgical services most frequently requiring authorization, those most frequently approved, and those where authorization is initially denied and then overturned on appeal. Carriers must also report on their average response time for prior authorization requests. This information will help increase transparency and strengthen WSMA’s advocacy by improving lawmakers’ understanding about the effect prior authorization has on access to care.

At the WSMA we are working on our 2023 legislative agenda, and we anticipate our work is far from over on this topic.