Nearly 97% of providers have seen delays or denials for necessary patient care due to prior authorization requirements, according to the Medical Group Management Association’s 2023 “Regulatory Burden Report.”
Further, according to Medscape‘s 2024 “‘They’re Awful and Impede Patient Care’: Medscape Physicians and Prior Authorizations Report 2024,” more than 7 in 10 physicians told Medscape that they believe the cost of prior authorizations are higher, or much higher, than they were three years ago.
Andrew Lovewell, CEO of Columbia (Mo.) Orthopaedic Group, described a “cyclical” pattern of repeated denials for treatment plans and procedures and frustration among physicians who feel burdened by peer-to-peer reviews and inconsistent communication by payers.
“It’s becoming such a joke that we’re having to deal with all of these hoops to jump through just to take care of patients,” he told Becker’s.
In its recently proposed reforms to the Medicare Advantage and Part D programs for 2026, CMS is looking to “address concerns about the overuse of prior authorization” by clearing up definitions for internal coverage criteria, creating stricter transparency requirements for payers, ensuring enrollees are informed about their rights to appeal and collecting more data on initial coverage decisions and appeals.
A bipartisan group of legislators in Congress has also reintroduced the Improving Seniors’ Timely Access to Care Act, which would reform prior authorization requirements in Medicare Advantage plans. ACG has developed an advocacy tool to support this legislation.
While the changes represent some attention on the matter from lawmakers, they may not go far enough to satisfy physicians’ concerns.
When given options of different reforms for prior authorization procedures, 51% of the physicians surveyed in the Medscape report said that they supported uniformity among payers. Another 19% said that greater automation on the provider’s end would help, 12% supported a central database of procedures, and another 8% and 9% supported more e-filing options from payers and other options, respectively.
