Physicians urge Congress to address prior authorization reform

May 21, 2021

Given the insurance industry’s lack of progress in voluntarily reducing the burdens of prior authorization agreed to in the consensus statement, the American Medical Association (AMA) stated it is calling on Congress to remedy the problem.

AMA continued:

At the height of the COVID-19 pandemic, physicians reported being bedeviled by unnecessary, bureaucratic obstacles that the health insurance industry pledged to reduce three years ago. The data highlights the urgent need for new bipartisan legislation introduced this week in the House, the Improving Seniors’ Timely Access to Care Act (HR 3173). The act takes direct aim at the insurance industry’s foot-dragging and would codify much of the consensus statement.

This bipartisan legislation would require Medicare Advantage (MA) plans to implement a streamlined electronic prior authorization process that complies with technical standards developed by the Department of Health and Human Services, in consultation with relevant stakeholders. In addition, the bill would require increased transparency for beneficiaries and providers, as well as enhance oversight by the Centers for Medicare & Medicaid Services on the processes used for prior authorization.

Moreover, to ensure that routinely approved care and treatments are not subjected to unnecessary delays, the program would provide for real-time decisions by an MA plan with respect to certain prior authorization requests.  Importantly, the bill would also require MA plans to meet beneficiary protection standards, such as ensuring continuity of care when patients change plans.

An AMA-conducted survey shows that physicians are running into roadblocks because of prior authorization, or the process of requiring healthcare professionals to obtain advance approval from health plans before a prescription medication or medical service is delivered to the patient. The 1,000 practicing physicians surveyed in December 2020—when new COVID-19 cases were soaring — reported that prior authorization was widespread. 83%of respondents indicated that prior authorizations for prescription medications and medical services have increased over the past five years. Along with this increased volume of requirements, most physicians reported a continued lack of transparency in prior authorization programs, with a majority of physicians stating that it is difficult to determine whether a prescription medication (68%) or medical service (58 %) requires prior authorization. An overwhelming majority (87%) of physicians also reported that prior authorization interferes with continuity of care.

This grim reality persists despite the fact that three years ago, the AMA and other large health organizations signed a consensus statement that was intended to improve the prior authorization process. The AMA, along with the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and the Medical Group Management Association, agreed to reforms needed to reduce prior authorization burdens and enhance patient-centered care.

AMA has the release.