prior authorization

Prior authorization has become the standard instance of well-intentioned healthcare policies gone wrong. Finding skilled staff to handle prior authorization is essential for healthcare organizations.

The Root of the Problem

The current system was designed to avoid low-value or unnecessary medical services by needing insurer approval before requesting specific operations, tests, or treatments. It has come under fire from provider associations for impeding access to essential care.

94% of doctors experienced service delays related to prior authorizations in a 2022 American Medical Association poll (AMA) poll. 89% of doctors said the procedure had a slightly or very negative effect on clinical results.

Attempting to Make a Difference

Before joining hands in a 2018 consensus statement to enhance the process, doctors and insurers have both attempted to find chances for significant prior authorization reform. However, the increased influence of state and federal legislators may now greatly advance the parallel objectives of protecting expensive, inefficient treatment and alleviating medical professionals and patients of excessive regulations.

Because of the pandemic’s acceleration of already high rates of burnout among health workers due to administrative demands and other factors that undermine autonomy and obstruct professional fulfillment. Additionally, the quantity of prior authorization requests keeps increasing. 79% of the medical groups surveyed by the 2022 Medical Group Management Association stated that prior requirements had grown in the previous year. According to a study, Medicare Advantage Plans alone received over 35 million prior authorization requests in 2021, and 82% of appeals led to the full or partial reversal of initial denials.

Differences in Requirements

Each insurer has various requirements on the kind of care requiring prior authorization, how requests are made and contested, and the timeframe for making a decision. Denial letters frequently don’t include enough information as to why a request was turned down, necessitating time-consuming follow-up. In the AMA study, 35% of doctors worked with employees who were solely responsible for previous authorizations.

For patients, things are not much better. They experience the unintended consequence of health inequalities because many people lack the time or means to pursue a prior authorization request.

Things are Looking Better for the U.S.

The American healthcare system is moving in a direction that should encourage more equitable, productive, and successful prior authorization protocols while discouraging the use of unnecessary or poor-quality services. At least 40 states are contemplating alternatives. Likewise, organizations like AHIP and the AMA widely support numerous suggestions made by the Centers for Medicare & Medicaid Services.

A number of innovative concepts are included in the Medicare Advantage, Medicaid managed care, and Affordable Care Act exchange plans that will launch in January 2026. Automating the procedure by which providers determine if prior authorization is necessary is one example. Another new idea speaks of easing resubmission when necessary and encouraging improved communication between payers and providers.

It’s essential to understand the original intent of prior authorization requirements as new guidelines for the upcoming wave of regulations become available. Prior authorization seeks to implement patient- and provider-friendly, evidence-based measures that enhance equity and overall healthcare outcomes while avoiding unnecessary or harmful care.

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BroadPath. (2023, April 13). Efforts to reform prior authorization gaining traction. Retrieved from: