Prior authorization requires providers to get approval from insurers before delivering certain treatment, tests or medical services.
The policy is intended to minimize costly procedures and act as a check on potentially unnecessary, inappropriate or unsafe medical treatments.
But the AMA and other medical societies say that it is an inefficient procedure that requires practices to hire more staff and frequently causes patient delays, which often leads to patients abandoning treatment.
“Prior authorization is a tool used by payers to ration healthcare and improve their quarterly balance sheets,” Lali Sekhon, MD, PhD, of Reno-based Nevada Neurosurgery, told Becker’s. “I have worked in a world (Australia) where there was no prior authorization and decisions were left to the treating physician. It works. The American system enables profits for payers by using gatekeeper functions beyond treating physicians.”
The Improving Seniors’ Timely Access to Care Act was introduced to the House in May. The legislation would:
- Require Medicare Advantage plans to install an electronic prior authorization process that complies with HHS standards
- Require increased transparency for beneficiaries and providers
- Increase CMS oversight on processes used for prior authorization
- Provide for real-time decisions by a Medicare Advantage plan for certain prior authorization requests
- Require Medicare Advantage plans to meet beneficiary protection standards, such as ensuring continuity of care when patients change plans.
“There is no room in the patient-physician relationship for insurance-industry barriers. The AMA is dedicated to simplifying and right-sizing prior authorization so physicians can properly provide care and patients can receive the timely treatment they deserve,” AMA President Susan Bailey, MD, said in a May 14 news release. “This legislation is a win-win for patients and physicians.”
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