When patients arrive at the pharmacy to fill a prescription, they may be unexpectedly told that their insurance company requires additional approval before covering the medication. This process, known as prior authorization, forces healthcare providers to submit extensive paperwork—often delaying treatment for days, weeks, or even months. For individuals living with headache disorders and migraine disease, these delays can mean prolonged pain, reduced quality of life, and increased risk of worsening symptoms.
Prior authorization is intended as a cost-control measure for insurers, but in practice, it creates unnecessary hurdles for patients and healthcare providers. The National Headache Foundation opposes prior authorization policies that limit timely access to medically necessary treatments and burden both patients and clinicians with excessive red tape.
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
