AGA supports reducing prior authorization burdens that delay patient access to care

AGA position: Patients should have timely access to the care their health care providers deem medically necessary. 

Prior authorization is a utilization management tool used by insurers that requires physicians to obtain pre-approval for medical treatments or tests before rendering care to their patients. The process for obtaining approval is lengthy and typically requires physicians or their staff to spend the equivalent of two or more days each week negotiating with insurance companies — time that could have been spent taking care of patients. Prior authorization is not only an administrative hassle that impacts physicians’ ability to provide timely care to patients, but patients are now experiencing significant barriers to medically necessary care due to prior authorization requirements for services that are eventually routinely approved. 

Recent surveys of specialty physicians have found that:

  • Nearly 90% of physicians have delayed or avoided prescribing a treatment due to the prior authorization process.
  • 95% report that the increased administrative burden has influenced their ability to practice medicine.
  • 82% of specialty physicians state that prior authorization either always (37%) or often (45%) delays access to necessary care.
  • Prior authorization causes patients to abandon treatment altogether with 32% reporting that patients often abandon treatment and 50% reporting that patients sometimes abandon treatment.
  • Nearly two-thirds report having staff who work exclusively on prior authorizations, with one-half estimating that staff spend 10-20 hours/week dedicated to fulfilling prior authorization requests and another 13% spending 21-40 hours/week.
  • Ultimately, the majority of services are approved (71%), with one-third of physicians getting approved 90% or more of the time.
Medicare Advantage     

One in every three people with Medicare is enrolled in a Medicare Advantage (MA) plan. Under current law, MA plans may not create inappropriate barriers to care that do not already exist within the original Medicare program. However, physicians are reporting that MA plans have imposed increasingly onerous prior authorization requirements for medical services and procedures that are impacting patient access to medically necessary care. AGA and the physician community are advocating for changes related to how MA plans use prior authorization. Physicians and patients need a simpler process that is less burdensome on our ability to provide care.   

Improving Seniors Timely Access to Care Act

Reps. Suzan DelBene, D-WA, Mike Kelly, R-PA, Roger Marshall, MD, R-KS, and Ami Bera, MD, D-CA, have introduced H.R. 3107, the Improving Seniors Timely Access to Care Act, legislation that would streamline prior authorization in the MA program.  Specifically, the legislation would increase transparency and accountability of MA plans by:

  • Establishing an electronic prior authorization process.
  • Minimize the use of prior authorization for services that are routinely approved.
  • Prohibit additional prior authorization for medically-necessary services performed during a surgical or invasive procedure that already received or did not initially require prior authorization.
  • Ensure prior authorization requests are reviewed by qualified medical personnel.
  • Require plans to report on the extent of their use of prior authorization and the rate of delays and denials.
  • Ensure plans adhere to evidence-based medical guidelines.