Prior Authorization Legislation: A Comprehensive Guide to Reform Efforts

Prior authorization legislation has been a hot topic in the healthcare industry, with many states and organizations working to reform the process. The goal is to reduce administrative burdens and improve patient access to necessary treatments.

In 2019, a report by the American Medical Association found that prior authorization requests increased by 15% from 2017 to 2018. This highlights the need for reform efforts to address the growing administrative burden on healthcare providers.

The 21st Century Cures Act, passed in 2016, included provisions to reduce prior authorization requirements for Medicare-covered services. This is a step in the right direction, but more work is needed to address the complexities of the prior authorization process.

Studies have shown that prior authorization delays can lead to increased healthcare costs and reduced patient satisfaction. By streamlining the prior authorization process, healthcare providers can focus on delivering quality care rather than navigating bureaucratic red tape.

Legislative Activity has been a key area of focus for prior authorization reform. At least 57 bills have been introduced in 22 states to reform prior authorization requirements for procedures, tests, treatment, and prescriptions.

Some of these bills contain provisions that require insurers to respond to requests within a certain timeframe, such as 24 hours for urgent requests or 48 hours for non-urgent requests. This is an effort to reduce the administrative burden on healthcare providers.

Other bills propose that prior authorization requirements must be evidence-based, such as being based on peer-reviewed clinical data. This ensures that decisions are made with the most up-to-date and reliable information.

The concept of "Gold Card" legislation has also been explored in some states. This would exempt physicians with high prior authorization approval rates from prior authorization requirements on specified services. So far, Michigan, Louisiana, Texas, and West Virginia have enacted such laws.

Here is a breakdown of some of the committee actions taken on prior authorization legislation:

It's worth noting that these actions are just a few examples of the many steps taken in the legislative process. The outcome of these bills will depend on the specific language and provisions included.

The momentum to reform prior authorization is building, with nine states and the District of Columbia passing legislation in 2023 to improve the process for patients and physicians.

Lawmakers are taking action to address the unnecessary harm caused by prior authorization, which has been a major concern for patients and physicians alike. This is a step in the right direction, as it will help reduce administrative burdens and improve patient care.

The American Medical Association (AMA) has been advocating for reforms, and their efforts are paying off. In January, the Centers for Medicare & Medicaid Services (CMS) released a final rule that is expected to save physician practices an estimated $15 billion over 10 years.

The AMA is also providing model legislation for states to draw from, which includes reforms such as reducing plans' time to respond to prior authorization requests and ensuring that only a qualified physician makes adverse determinations.

Here are some key reforms included in the AMA's model legislation:

More than 90 bills have been introduced in legislatures across 30 states so far this year, with several states, including Minnesota, Wyoming, Massachusetts, Oklahoma, and North Carolina, having comprehensive prior authorization reform bills pending.

The AMA's fight to eliminate care delays, patient harm, and practice hassles is ongoing, with updates on prior authorization improvements.

New laws and regulations are being passed to simplify the prior authorization process, making it easier for doctors to get approval before providing care.

Tennessee's law ensures that once a physician gets initial approval, an insurance company can't later deny it, often after the service has already been provided.

This is good news for patients, who can now get the healthcare they need without worrying about being asked to pay for the service later.

In New Jersey, a new law creates standards that ensure physicians reviewing prior authorization requests or denial appeals have a background in the treatment being requested.

Physicians in Texas can no longer be required to undergo more than one prior authorization annually for a prescription drug prescribed to treat certain conditions.

Carriers in Tennessee, Arkansas, Washington state, Louisiana, Montana, Rhode Island, West Virginia, and Texas have also updated their laws to address prior authorization concerns.

These changes aim to streamline the process, reduce appeals, and provide clarity on nationally recognized standards for prior authorization.

The prior authorization legislation has taken an interesting turn. The AMA, AHIP, Blue Cross Blue Shield Association, and American Hospital Association have formed an unusual alliance to express concerns about CMS's approach to prior authorization processes.

They're worried that CMS is setting the stage for multiple prior authorization electronic standards and workflows, which would cause widespread industry confusion. This could be a major headache for health plans and providers.

The groups are concerned that implementing technologies to meet the requirements of both sets of standards would be enormously expensive.