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Streamlining the process of prior authorization for medical and surgical procedures

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Sens. Sherrod Brown (D-Ohio) and John Thune (R-S.D.) have done a great service to their constituents and to their nation by introducing the Improving Seniors’ Timely Access to Care Act. This is the much anticipated Senate companion to H.R. 3107 the Protecting Seniors Timely Access to Care Act. It should be a pivotal stepping stone for health care reform in the new administration.

This crucial bipartisan legislation can streamline the cumbersome process of prior authorization for medical and surgical procedures performed through Medicare Advantage programs.

The focus is on transparency via a real-time electronic prior authorization process with minimal utilization of prior authorization for routinely approved services. Most importantly, this bill requires regular reporting from the Medicare Advantage plan as to the rates of delay and denial of services.

Prior authorization is the opaque filibuster of health care; it doesn’t serve patients, and it’s been going on for years. Insurance companies drag their feet and tight clinch their financial fists in an attempt to reduce unnecessary expenditures. The challenge is that it’s not always rooted in science, and as our research group previously published in a peer-reviewed scientific paper, it delays care.

It’s something as a practicing physician, I have to deal with in a direct or indirect capacity on a near daily basis.

The administrative burden is staggering, and the bandwidth to manage all of this is crippling. 

We run an academic neurosurgery practice at a tertiary university referral center. My specific practice surrounds spinal deformity, scoliosis, and spinal trauma. In short, these are very sick patients that require tremendous pre-operative care, serious patient discussions, operative intensity, and a potentially challenging postoperative course. We simply don’t have the time to navigate all the different and somewhat arbitrary hoops for prior authorization for everything from physical therapy to rehabilitation placement to MRI screening.

Our staff, especially my nurse and our team of physician assistants/nurse practitioners, spend too much time faxing forms, staying on hold, and checking the check boxes needed instead of interacting with patients. It adds to the burnout problem.

This bill attempts to correct that error by creating a more open electronic process.

Most importantly, at the patient level, this current cumbersome prior authorization apparatus can delay care and frustrates patients. COVID-19 has already caused patients to delay seeking care which can result in worse health outcomes. I saw that firsthand when I treated COVID-19 intensive care unit patients in New York. We have pre-published preliminary research surrounding that issue. A non-functioning prior authorization system exacerbates this issue especially as patients and practices morph into a hybrid of in-person and virtual care delivery.

Finally, this legislation is becoming even more important as physicians were threatened with potential steep income cuts in 2021 by reduction of the conversion factor used for Medicare reimbursement. Reducing administrative burden will be a much welcomed reprieve. For providers, in 2019, processed prior authorization led to $528 million in administrative costs alone.

This legislation has gained support from the Regulatory Relief Coalition (RRC), a group of national physician specialty organizations, because it can help surgeons provide better and more streamlined care to patients. It’s a great first step. The real solution will come when the America health-insurance system puts less space between the parties that receive and provide care and those who pay for it. Reducing the footprint of prior authorization bends the arc towards that proper direction of reform.

Richard Menger MD MPA is an Assistant Professor of Neurosurgery and an Assistant Professor of Political Science at the University of South Alabama. He is the lead editor of the textbook The Business, Policy, and Economics of Neurosurgery.

Tags John Thune Sherrod Brown

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