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Senator Emphasizes that Prior Authorization Has Become the Foremost Issue for Physicians and Administrators in 2023

January 27, 2023

The issue of prior authorization in healthcare has been highlighted as the “No. 1 physician and administrative concern in America,” according to Kansas Senator Roger Marshall, MD, who is sponsoring the Senate’s version of a bill aimed at reforming the Medicare Advantage prior authorization process.

Senator Roger Marshall, MD of Kansas declared that prior authorization is the foremost medical and administrative issue in America, especially after witnessing how it caused delays for infertility patients or high-risk patients during his career as an OB-GYN. 

Dr. Marshall highlighted his concerns about the impact of prior authorization on patient treatment, particularly for infertility patients and high-risk individuals, in a news release from his office on November 30.

Other attendees during a subcommittee hearing on mental health shared Dr. Marshall’s concerns. Ashley Weiss, DO, Director of Medical Student Education in Psychiatry at Tulane University School of Medicine, expressed the prior authorization procedure as “mind-numbing” and noted that obtaining prior authorization for community-based mental health care can sometimes take weeks.

The Senate is currently discussing Dr. Marshall’s version of the Improving Seniors’ Timely Access to Care Act. 

In September, the House of Representatives passed its own version of the measure.   The proposed law includes measures to establish an electronic prior authorization procedure and would compel Medicare Advantage plans to disclose to the Centers for Medicare and Medicaid Services (CMS) their usage of prior authorization as well as the rates of approval and rejection.

The bill was originally introduced in 2021, a bill that gained momentum this spring following a report by the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS). 

The report revealed significant findings regarding Medicare Advantage prior authorization request denials. According to the report, 13 percent of these denials would have been approved if the beneficiaries had been under the original Medicare coverage rules. 

Furthermore, the OIG report highlighted that 18 percent of denied payment requests met both Medicare coverage rules and Medicare Advantage Organization billing rules.

The growing recognition of the challenges posed by prior authorization and the efforts to reform the process reflect a broader acknowledgment of the need to streamline administrative burdens in healthcare. By simplifying and expediting the prior authorization process, the aim is to enhance timely access to care and improve overall patient outcomes. 

The progress of the bill through the legislative process will be closely monitored as stakeholders and policymakers work towards addressing this significant concern in the healthcare system.