Issue: Put “Patients Before Paperwork” by advancing policies that will eliminate unnecessary red tape and improve prior authorization processes for patients and their physicians.
Why Action is Needed
Unnecessary administrative requirements can prevent timely and appropriate treatment by forcing physicians to divert time and focus away from their patients. They can also be a financial burden and contribute significantly to the current burnout epidemic among physicians. Medicare Advantage plans can require enrollees to receive prior authorization before a service will be covered, and nearly all Medicare Advantage enrollees (99 percent) are in plans that require prior authorization for some services in 2023. Further, in 2022, a survey of more than 500 doctors from group practices found that 89 percent believe that regulatory burdens increased in the past year, and 82 percent responded that the prior authorization process is very or extremely burdensome.
Prior authorization is a common practice by health insurers to require physicians to first secure approval before moving forward with a patient’s medications, tests, or procedures. It involves paperwork and phone calls, as well as varying data elements and submission mechanisms that force physicians to enter unnecessary data in electronic health records (EHRs) or perform duplicative tasks outside of the clinical workflow. This inhibits clinical decision-making at the point of care and is an unnecessary burden for physicians and barrier to medical care for patients. The Department of Health and Human Services issued a report in 2022 that detailed abuse in the prior authorization process in which “Medicare Advantage insurers sometimes delayed or denied beneficiaries’ access to services, even though the requests met Medicare coverage rules.”
Another practice implemented by health insurers that can disrupt patient care and hinder access to treatment is step therapy, which aims to curb the costs of drugs but can create unnecessary administrative burden. It requires patients to try and fail at lower-priced drugs selected by their insurer before the drug prescribed by their physician is covered. ACP believes that there should be a transparent exceptions process for step therapy, to provide physicians and patients with clarity for treatment options and to prevent delays in care.
Further, physicians are increasingly faced with an overload of messages in their virtual inboxes, causing them to divert their time away from doing what they do best, treating their patients.
ACP’s Position and Advocacy
ACP’s Patients Before Paperwork initiative serves as the foundation for policy recommendations for revising, streamlining, or removing entirely burdensome administrative tasks. The framework and recommendations call attention to the need to better understand the daily issues physicians face, including prior authorization obstacles, in order to improve patient care.
In January 2024, the Centers for Medicare and Medicaid Services (CMS) issued a final rule requiring health plans to streamline their PA processes. The rule requires Medicare Advantage (MA) organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, and CHIP managed care entities to send PA decisions within 72 hours for expedited requests and seven calendar days for standard requests. The rule does not apply to commercial insurers.
ACP also advocates for prior authorization reform with private payers. In 2023, ACP successfully collaborated with other medical specialty societies to address egregious prior authorization requirements. Due to our advocacy efforts, United HealthCare changed its burdensome protocol for its gastrointestinal (GI) endoscopy prior authorization program and Cigna removed approximately 25 percent of medical services from prior authorization requirements.
At the federal level, ACP continues to advocate for legislative and regulatory policy changes that improve prior authorization and step therapy processes for patients and clinicians. We call on Congress to act now and do its part to improve physicians’ ability to provide seamless evidence-based care for their patients without unnecessary administrative delays.
Call to Action
- Support the Improving Seniors’ Timely Access to Care Act, which would require that Medicare Advantage (MA) plans establish an electronic prior authorization process for real-time decision making to make it easier for physicians to determine if a prescribed procedure, service, or medication is covered. ACP also supports streamlining prior authorization for other group health plans.
- Support the Safe Step Act of 2023, H.R. 2630/S. 652, a bipartisan bill that would ensure patient access to appropriate treatments based on clinical decision-making and medical necessity rather than arbitrary step therapy protocols. The bill would require group health plans to provide a transparent exception process for any medication step therapy protocol.
- Support legislation and rulemaking to improve electronic health records and streamline the adoption of standards in medical practices that would reduce burdensome administrative tasks.