PRIOR AUTHORIZATION
BACKGROUND
Prior authorization is a cumbersome process that requires physicians to obtain pre-approval for medical
treatments or tests before rendering care to their patients. The process for obtaining this approval is
burdensome and costly to physician practices, requiring physicians and their staff to spend an enormous
amount of time each week negotiating with insurance companies. As a result, patients are now experiencing
significant barriers to medically necessary care, even for treatments and tests that are eventually routinely
approved.
A recent survey of neurosurgeons conducted by the AANS and the CNS found the following:
- Eighty-two percent of respondents state that prior authorization either always (34%) or often (49%) delays access to necessary care.
- The wait time for prior authorization can be lengthy. For most neurosurgeons (67%) it takes between 2 to 14 days to obtain prior authorization, but for 22%, this process can take from 15 to more than 31 days.
- Prior authorization causes patients to abandon treatment altogether with 21% reporting that patients often abandon treatment and 60% reporting that patients sometimes abandon treatment.
- Overwhelmingly (88%), neurosurgeons report that prior authorization has a significant (37%) or somewhat (51%) negative impact on patient clinical outcomes.
- Ninety-one percent of neurosurgeons report that the burden associated with prior authorization has significantly increased over the past five years.
IMPROVING SENIORS’ TIMELY ACCESS TO CARE ACT
To bring needed transparency and oversight to the Medicare Advantage program, the AANS and the CNS are
urging Congress to adopt H.R. 3107, the Improving Seniors’ Timely Access to Care Act. Sponsored by Reps.
Suzan DelBene (D-Wash.); Mike Kelly (R-Pa.); Roger Marshall, MD, (R-Kan.); and Ami Bera, MD, (DCalif.), the bill would protect patients from unnecessary prior authorization practices that limit their timely
access to medically necessary care. Specifically, this legislation would:
- Establish 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; and
- Ensure that plans adhere to evidence-based medicine guidelines.
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