Prior Authorization
When patients go to the pharmacy to fill a prescription, they are often told that their insurance company won’t pay for the medication unless a physician obtains approval. Patients may wait days, weeks or even months. This tactic, used by insurance companies to control costs, is called prior authorization.
Federal Engagement
H.R. 4968, the Getting Over Lengthy Delays in Care as Required by Doctors Act of 2023
Would exempt physicians from Medicare Advantage plan prior authorization requirements so long as 90% of the physicians’ prior authorization requests were approved in the preceding 12 months.
- Medicare Advantage plan-issued gold cards would be applicable only to items and services—and exclude drugs—and remain in effect for at least a year.
- The legislation is based on a similar law enacted in Texas that took effect in 2021.
State Engagement: States are responding to complaints from physicians and patients and pursuing legislation to try to set some ground rules on prior authorization.
“Prior authorization continues to serve as a chief frustration for physicians due to its excessive use, opacity, responsibility for delaying and denying patient care, and direct correlation with poorer health care outcomes,” said American Medical Association President Jesse M. Ehrenfeld, MD, MPH.
Insurance Payer Engagement
UnitedHealthcare announces Gold Card program for some prior authorizations
UnitedHealthcare (UHC) has announced it will launch a Gold Card program October 1, 2024 intended to ease some prior authorizations. Practices that qualify will receive a streamlined prior authorization process for certain medical, behavioral, and mental health services
