Prior Authorization

Why D.C. Council should act now to fix prior authorization

Kevin B. O'Reilly , Senior News Editor

What’s the news: The AMA has joined the Medical Society of the District of Columbia (MSDC) to support a bill to reform prior authorization, the health insurer-imposed approval processes for medical procedures, treatments and drugs.

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In a letter sent to the Council of the District of Columbia’s Committee on Health, the two physician organizations urged action on the “Prior Authorization Reform Act of 2022” as a critically needed measure to rein in bureaucratic insurance requirements that delay and disrupt patient access to necessary medical care in the nation’s capital city.

The bill would realign what has become a very broken system by introducing new transparency and clinical validity requirements to ensure patients have access to care.

“Prior authorization is one of the biggest impediments to patient care, and this legislation would allow physicians to treat their patients without unnecessary paperwork and delays,” said MSDC President Kirstiaan Nevin, MD.

Find out how a new physician “gold card” law will cut prior authorization delays.

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I’m used to my patients’ prior auth hassles. Then came Mom’s.

Why it’s important: Survey data (PDF) released in February by the AMA shows that 93% of physicians reported care delays while waiting for health insurers to authorize necessary care, and 82% of doctors said patients abandon treatment due to authorization struggles with health insurers. Learn how the AMA survey reveals that prior authorization is bad for patients and bad for business.

Despite a 2018 commitment from the health insurance industry to streamline prior-authorization processes for patients, physicians report that the burden is dramatically rising, causing a variety of problems for their patients and their practices. Indeed, 34% of physicians reported that prior authorization led to a serious adverse event, such as hospitalization, disability or even death, for a patient in their care.

“Providing quality care to patients is the top priority of physicians, but waiting for a health plan authorization can delay and disrupt patient-centric care with a lengthy administrative nightmare of recurring paperwork, multiple phone calls and bureaucratic battles,” said AMA President Gerald E. Harmon, MD.

“Almost four years after agreeing with physicians on needed improvements, the health insurance industry has made little progress toward those goals,” Dr. Harmon added. “Failure of health insurers to achieve agreed-upon improvements illustrates a clear opportunity for District councilmembers to rein in prior authorization requirements that adversely impact patient health.”

In an AMA Leadership Viewpoints column, Dr. Harmon reflected on his own mother’s experience as a patient with the exasperating prior authorization process and why it needs to be fixed.

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Q&A: A drug changed this M4’s life. Prior auth nearly upended it.

Learn more: In Washington’s other legislative body, Congress, the AMA supports the bipartisan “Improving Seniors’ Timely Access to Care Act” that was reintroduced by Reps. Suzan DelBene, D-Wash; Mike Kelly, R-Pa.; Ami Bera, MD, D-Calif.; and Larry Bucshon, MD, R-Ind. The measure would improve access to care by streamlining and standardizing the way Medicare Advantage plans use prior authorization, and by increasing oversight and transparency around these programs.

Prior authorization hurts patients, physicians and employers. Share your prior-authorization story and find out how you can take action to help #FixPriorAuth.