LUGPA Policy Brief: Prior Authorization Reform - State and Federal Efforts

Oct. 2024

Prior authorization has become a significant administrative burden for physicians and a source of patient care delays. Designed to control costs, prior authorization often delays necessary treatments, negatively impacts patient care, and creates inefficiencies for healthcare providers. As a result, states and federal lawmakers are taking action to reform how insurers use prior authorization, seeking to reduce the burden on both patients and physicians.

State-Level Reforms

According to the American Medical Association, in 2024, at least 10 states passed laws aimed at reforming prior authorization processes. These reforms focus on reducing the number of procedures requiring prior authorization, cutting patient care delays, improving transparency, and increasing data reporting on PA decisions.

The following states enacted key reforms this year:

• Vermont: Patients with chronic conditions no longer need repeated prior authorizations for ongoing treatment. When a patient changes coverage, insurers must accept prior authorizations from previous health plans for up to 90 days, and urgent prior authorization requests must be addressed within 24 hours.
• Minnesota: New legislation prevents PA requirements for non-medication aspects of cancer and mental health care. For chronic conditions, PA remains valid as long as treatment doesn’t change, reducing the need for frequent renewals. Minnesota also mandates comprehensive PA data reporting to the state health department.
• Wyoming: A new “gold card” program exempts physicians from PA requirements when they consistently receive approvals for procedures or medications. The law also accelerates response times for PA requests and requires insurers to honor existing prior authorizations during plan transitions.

Other states, including Illinois, Colorado, Mississippi, Maine, Maryland, Oklahoma, and Virginia, have passed similar measures aimed at curbing the prior authorization burden. These reforms ensure that PAs are less frequent, decisions are made faster, and the process is more transparent for patients and physicians.

Federal Efforts

At the federal level, the Improving Seniors’ Timely Access to Care Act of 2024 (HR 8702/S 4518) represents a potential step toward streamlining prior authorization in Medicare Advantage (MA) plans. The bipartisan legislation, reintroduced in Congress, seeks to reduce delays for older Americans by establishing clear standards and requiring quicker responses for prior authorization requests.

The bill focuses on:

• Creating an electronic PA process for Medicare Advantage plans to expedite requests.
• Standardizing transactions and clinical attachments to streamline the approval process.
• Requiring transparency in PA requirements and ensuring timely decisions for routine procedures.
• Protecting beneficiaries by extending PA validity for chronic condition treatments and requiring new insurers to honor prior authorizations from previous plans for at least 90 days.

LUGPA's Position on Prior Authorization

LUGPA has long advocated for reducing prior authorization requirements, arguing that they create unnecessary delays in patient care and impose administrative burdens on physicians. In May 2024, LUGPA submitted feedback to the Centers for Medicare & Medicaid Services (CMS) regarding prior authorization reforms within the Medicare Advantage program, supporting efforts to increase transparency and reduce burdens on specialty care providers.

LUGPA’s key recommendations include:

1. Enforcing Timely Decisions: Prior authorization decisions should be made promptly to ensure patients receive timely care.
2. Limiting Documentation Requirements: Overly complex documentation should be minimized, especially for routine or low-risk procedures.
3. Specialty Care Considerations: CMS should collect data on prior authorization requests for specialty services, including urology, to monitor the impact on high-cost, complex treatments.

LUGPA strongly supports the Improving Seniors' Timely Access to Care Act and other state and federal efforts to reform prior authorization processes. By reducing administrative burdens and eliminating unnecessary care delays, these reforms will ensure that patients receive the care they need when they need it.

Prior authorization reform is gaining momentum at both the state and federal levels, with a clear focus on reducing delays, enhancing transparency, and easing the administrative load on healthcare providers. LUGPA continues to support legislative efforts prioritizing patient care, particularly in specialty fields like urology. We remain committed to working with policymakers to create a healthcare environment where prior authorization no longer stands in the way of timely and appropriate patient care.