Prior Authorization

Our Position

Congress must take action to reform the overly burdensome prior authorization process.

The Academy strongly supports the Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018), bipartisan legislation that would streamline and standardize the prior authorization process under the Medicare Advantage (MA) program, remove barriers to accessing care for Medicare patients, and help relieve the unnecessary administrative burden our physician members currently face.

Background

Prior authorization is a process created by health insurance companies that requires physicians to obtain approval before providing care to patients for covered services. This burdensome process increases the time required for a physician to diagnose and treat a patient — delaying the patients’ access to care and potentially putting their health at risk.

In otolaryngology, insurers’ use of prior authorization has increased significantly in recent years. ENT offices currently complete more than 40 PAs per week on average and many offices have staff dedicated solely to performing prior authorization. Many basic ENT procedures now require prior authorization and each insurance company has its own PA requirements. The result is a patchwork system that is increasingly complex and contributing to physician burnout and stress.

Congress can protect patients by reforming prior authorization

The Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018) would create sensible rules to relieve the administrative burden physicians face with prior authorization under the MA program. Insurers would be required to provide information on the care subject to PA, the average time PA approvals take, and the percentage of PA requests that are approved and denied.

This bipartisan legislation would also:

  • Establish a PA program that provides real-time decisions in response to requests for items and services that are routinely provided
  • Create a secure electronic PA (ePA) process and require MA plans to adopt ePA capabilities
  • Ensure PA requests are reviewed by a qualified medical professional
  • Increase transparency requirements by publishing specified PA information
  • Ensure continuity of care when a patient transitions between MA plans
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