Nearly everyone has a story of how health insurers’ use of prior authorization interfered with them or a loved one getting a needed procedure done, receiving treatment for cancer or another disease or gaining access to a vital medication, perhaps one that a patient has been on successfully for years.
Lawmakers are no exception, and their experiences are leading some at the state level to take the lead on trying to change the system, including Illinois.
The Illinois State Medical Society began a focused advocacy effort for changes to prior authorization in 2019. In 2021, state lawmakers passed their first big reforms, and the legislature continues to ease burdens, including new measures this year.
“Anytime you can take a burden and decrease that burden, you then allow more time” for doctors and patients, said Richard Anderson, MD, the state medical society’s president-elect. “By taking away some of that burden in prior authorization, it gives physicians more time to spend with their patients. And what it's also going to do, it's also going to help speed up our process of making our patients healthier sooner by decreasing that time.”
The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles. On a recent episode of “AMA Update,” Dr. Anderson detailed successful advocacy efforts in the Land of Lincoln.
What Illinois accomplished
In a win for patients and physicians, Illinois achieved many of the things that the AMA is calling for to be changed, including:
- Standardizing response times after a request is made. Utilization-review organizations must respond within five calendar days of receiving all necessary information for nonurgent care. For urgent care, a response is required within 48 hours. The AMA calls for even faster response times.
- Defining who qualifies as a “peer” when a decision requires a peer review. If a prior authorization request requires a peer review, the reviewer must be in a specialty related to the physician making the request to deny a claim.
- Establishing timelines for how long an approval is good for, with differing timelines for acute and chronic, or long-term, conditions. For continuity of care when a patient switches insurers, the law requires existing prior authorization approvals be honored for at least 90 days under the new insurer.
- Requiring insurers to be transparent about what is required for prior authorization. Individual insurance carriers must provide guidelines on their website, or wherever they publish items, explaining what is required for prior authorization. They also must follow clinically relevant guidelines.
While those were big changes, the push for further reforms continues. For example, this year Illinois passed laws to get rid of step therapy, eliminate prior authorization for certain emergency mental health treatments and remove prior auth requirements for higher doses of buprenorphine used to treat substance-use disorder.
How Illinois physicians succeeded
The quest to make changes in Illinois started in 2019 when the state medical society put together a group of health care advocacy leaders and patients to work on being able to describe for lawmakers the burdens prior authorization creates and present a plan to decrease those burdens, Dr. Anderson said.
First, the medical society polled its own membership and saw their concerns with prior auth, which were similar to ones revealed in an AMA annual survey of 1,000 physicians about prior authorization (PDF). From there, they formed a coalition of patient-advocacy groups and patients, gathering stories from physicians and patients. They created the “Your Care Can’t Wait” campaign and met with lawmakers, used an AMA model bill (PDF) to help craft draft legislation and looked to other states to see what they were able to accomplish.
“This was a very powerful grassroots effort,” Dr. Anderson said. “We need to get rid of the bureaucracy of prior authorization. And we need to make it a public health priority, and take the politics out of it.”
Changes a must at federal level
States continue to make progress on prior authorization, with nearly a dozen tackling it in some way this year.
And there has been some progress at the federal level. In January, the Centers for Medicare & Medicaid Services released a final rule that cut patient care delays and electronically streamlined the prior authorization practice for physicians. The changes—which apply to government-regulated health plans including Medicare Advantage and Medicaid managed care plans—are expected to save physician practices $15 billion over 10 years.
Congress is poised to potentially take action to improve prior authorization this year. Bipartisan groups in the House and Senate have introduced legislation that would streamline and standardize how Medicare Advantage uses prior authorization. The AMA supports the legislation, called the Improving Seniors’ Timely Access to Care Act of 2024.
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