Prior Authorization Resources

Challenging prior authorization policy requirements were addressed in an AHA Annual Membership Meeting panel discussion moderated by Marilyn Werber Serafini, executive director for the Health Program at the Bipartisan Policy Center.

The Change Healthcare cyberattack was a significant event that caught many off guard, said the Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure, reiterating the age

People enrolled in Medicare Advantage are more likely than those in traditional Medicare to report delays in care due to needed insurance approvals, according to a survey released Feb. 22 by the Commonwealth Fund, with 13% of traditional Medicare enrollees reporting associated delays compared with 22% of MA enrollees.

Andrea Preisler, AHA’s senior associate director of administrative simplification policy, explains why the recent final rule requiring Medicare Advantage, Medicaid and federally facilitated Marketplace plans to streamline their prior authorization processes should help reduce the burden on hospitals and clinicians and speed needed care for patients.

The Centers for Medicare & Medicaid Services Jan. 17 released a final rule requiring Medicare Advantage, Medicaid and federally facilitated Marketplace plans to streamline their prior authorization processes. AHA has urged the agency to finalize the rule to alleviate provider burden and ensure timely access to care for patients. 

Rick PollackPresident and CEOAmerican Hospital Association

AHA urged the Centers for Medicare & Medicaid Services to quickly finalize a proposed rule that would require Medicare Advantage, Medicaid and federally facilitated Marketplace plans to streamline their prior authorization processes.

In an Aug. 28 letter to House sponsors, the AHA voiced support for the GOLD Card Act of 2023 (H.R. 4968) that would exempt qualifying providers from prior authorization requirements under Medicare Advantage plans.

UnitedHealthcare Aug. 1 published a list of procedures no longer subject to prior authorization effective either Sept. 1 or Nov. 1, 2023.

A bipartisan group of 233 representatives and 61 senators called on the Centers for Medicare & Medicaid Service to enhance its proposal to streamline prior authorization processes in Medicare Advantage, Medicaid and the federally-facilitated Marketplace to require real-time electronic decision-making for routinely approved services, responses for emergency procedures within 24 hours and additional transparency.

The Department of Health and Human Services should adopt its proposed standard for claims attachments to help improve claims processing and eliminate unnecessary burdens on health care providers, AHA said in comments submitted today.

AHA today urged the Centers for Medicare & Medicaid Services to quickly finalize a proposed rule that would require Medicare Advantage, Medicaid and federally-facilitated Marketplace plans to streamline their prior authorization processes, but urged the agency to adequately enforce and monitor the requirements and test and vet any electronic standards before mandating their adoption.

The Centers for Medicare & Medicaid Services tonight released a proposed rule that would require Medicare Advantage, Medicaid and federally-facilitated Marketplace health plans to streamline processes related to prior authorization.

The AHA commends CMS for taking important steps to remove inappropriate barriers to patient care by streamlining the prior authorization process for some health insurance plans. Hospitals and health systems especially appreciate that CMS included Medicare Advantage plans in these requirements, as the AHA has urged.

Certain commercial health insurer policies and administrative practices delay patient care, overburden clinicians and withhold critical payments from providers.

AHA today released the special edition podcast “How Prior Authorizations Can Harm Patient Care,” addressing how some health plan prior authorization policies delay or deter necessary patient care, potentially putting patients’ lives at risk.

The cost of commercial insurance is increasing at an unsustainable rate — squeezing individuals and families, employers, and public programs. The average family insurance premium has increased 47% over the past 11 years — faster than general inflation and more than any other part of the health care system.i

In comments submitted today to the Office of the National Coordinator for Health Information Technology, AHA said it “strongly supports creating a useable, scalable and efficient solution to help reduce prior authorization impacts on patients and providers.

The Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology seeks comments through March 25 to inform potential future rulemaking on how the ONC Health IT Certification Program could incorporate standards, implementation specifications and certification criteria to reduce the burden of prior authorization.

Inefficient prior-authorization processes, slow turnaround times, lack of transparency and inconsistent requirements by payers can lead to dangerous delays in patient access.