As a physician, the odds that you’ve had a negative experience related to the prior authorization process are (unfortunately) highly likely. According to the American Medical Association’s (AMA) 2023 Prior Authorization Physician Survey, 1 in 4 physicians report that prior auths “have led to a serious adverse event for a patient in their care.” Think about the toll that this takes on professionals whose primary job is providing lifesaving care, and the thing preventing this care is outside their control and in the hands of health insurance companies.
Even worse is seeing the toll a denied authorization takes on a patient’s health journey. Countless patient stories are making headlines outlining the adverse effects that a denied claim has had on access to care – some ending in the most devastating circumstances. As a physician myself, I can recount several pediatric cases where prior authorization denials and delays negatively impacted a patient right in front of my eyes.
Luckily, all the media attention and reform advocacy surrounding prior authorization is helping to move the needle toward better process management and efficiency. Progress is also being made on the legislative side. Various federal and state legislatures are focusing efforts on transforming the prior authorization process to increase patient access to care, decrease physician burnout, and improve overall health system operations. Some regulations focus on specific portions of the prior authorization process, while others zero in on certain health plans.
Recently, a bipartisan group of lawmakers reintroduced legislation to overhaul the prior authorization process of Medicare Advantage plans. The proposed bill – Improving Seniors’ Timely Access to Care Act – seeks to streamline the approval process, reduce administrative burdens for healthcare providers, and ensure patients receive timely access to necessary medical treatments.
It’s important to understand why this bill narrowly focuses on Medicare Advantage plans and what it hopes to solve. The rise of Medicare Advantage plans, which operate as HMOs, has led to a surge in prior authorizations. Unlike traditional Medicare, which is fee-for-service and rarely requires authorizations, MA plans aim to control utilization, adding layers of complexity for providers and patients. In fact, a recent KFF companion analysis noted that nearly all MA patients (99%) are enrolled in a plan that requires a prior auth for some services.
However, there are certain challenges related to the prior authorization process under Medicare Advantage plans. One significant barrier is the absence of clear guidelines on what requires authorization. Patients and providers often face confusion due to constantly changing rules and the difficulty in accessing this information. This issue is exacerbated by the fact that every MA plan has its own portal and some element of faxes, making the process cumbersome and inconsistent.
In general, the senior population has a more difficult time advocating for their care for a variety of reasons, including cognitive impairment, limited understanding of complex health issues, and unfamiliarity with portals and platforms holding important information about their care. Confusing prior auth processes are particularly challenging for the senior population, who may struggle to navigate the system and face delays in accessing necessary care. The complex nature of prior authorization under Medicare Advantage is so pronounced that some major health systems have opted out of contracting with MA plans, limiting patients’ access to their preferred providers.
The proposed Improving Seniors’ Timely Access to Care Act aims to address these issues by increasing transparency and accountability. From a patient perspective, the reforms will reduce delays and improve access to care. However, the success of these reforms hinges on effective communication and understanding of the new rules among the elderly population, who may lack the tech-savviness required to navigate modern healthcare systems. For providers, the new rules promise clearer turnaround times and more consistent prior auth requirements. However, the practical implementation of these rules remains a concern. The complexity of healthcare workflows, involving both federal and state regulations, may pose challenges in achieving the intended streamlining.
While implementation remains a major hurdle for this legislation, there are steps the industry can take to make adoption smoother. For example, there is a huge opportunity for automation to bridge the gap between legislative reform and practical implementation of new prior auth processes among health systems. Over 70% of current prior authorizations are processed manually because the flow of information and data interoperability is, in some cases, nonexistent in health systems.
Health systems and provider offices continue to struggle to keep up with the sheer amount of time required to manage the prior authorization workflow, especially since Medicare Advantage created a considerable increase in the volume of authorizations to be processed. Automation can help eliminate many of the manual tasks involved and cut down on the overall time needed to process the authorizations. Additionally, the tech can help provide real-time insights into the full process to pinpoint efficiencies or shortfalls on both the payer and provider side.
On the patient side, particularly for the senior population, automation can be used as a tool to take the onus off them by cutting down on the red tape that is currently, and unfortunately, a common occurrence prior to receiving care. Accelerating patient care is the goal, and automation, whether it be within the prior auth workflow process or determining when or why an authorization is required, is a welcome addition to the patient care continuum. Especially with the influx of legislative rules, demystifying the murky regulations and upcoming changes through automation is paramount to giving the control back to patients on their care journey.
Ultimately, we’re at a critical inflection point. The push to streamline prior authorizations in Medicare Advantage plans is a welcome development to reduce delays and improve care for seniors. However, you can’t force something without a clear roadmap. We need more discussion from stakeholders who understand the complexities of prior authorization workflows, constraints of EMRs, and general industry readiness for the changes proposed in the Improving Seniors’ Timely Access to Care Act. With the right approach, this legislation can lead to more efficient, transparent, and patient-centered care for seniors. But we have a way to go.
About Steve Kim
With over 20 years of experience, his passion for innovation, and his value-based delivery research background, Dr. Kim was the right person at the right time to take on front-end management. He co-founded Voluware, now known as Valer, to solve issues around highly manual prior authorization, referral, and eligibility workflows that he encountered at his own practice while at Children’s Hospital Los Angeles.
Dr. Kim was formerly an Assistant Professor at the University of Southern California Keck School of Medicine, where he served as the director of clinical research informatics for CHLA. He received his BS from Yale University and his MD from Cornell University Medical College. He earned a Master of Science in Clinical Epidemiology (MSCE) from the University of Pennsylvania and his MBA from the University of Southern California Marshall School of Business.