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Prior Authorization and Precertification Requirments are Increasing


Prior authorization is a process by which health insurance companies require healthcare providers to obtain approval before providing certain treatments, tests, or procedures. This process can be time-consuming. Providers and staff may have to call several numbers, wait on hold, have lengthy conversations with the insuance company the patient's care. If it is not clear a patient needs a prior authorization, claims deny and result in lost revenue for providers.


The Biden administration has set its sights on tackling the issue of prior authorization requirements in healthcare. The administration hopes to ease the burden of prior authorization requirements and improve patient access to care. In March 2021, the Centers for Medicare and Medicaid Services (CMS) issued a letter to insurers urging them to reduce the number of services that require prior authorization. The letter highlighted the negative impact prior authorization has on patient care and the potential for increased healthcare costs.


The CMS has also proposed changes to Medicare Advantage and Part D plans to reduce prior authorization requirements for certain drugs. The proposed changes would allow patients to receive certain medications without prior authorization, saving time and ensuring timely access to necessary medications.


In addition, the administration has issued an executive order to improve healthcare competition, which includes addressing the issue of prior authorization. The order directs the Department of Health and Human Services (HHS) to develop standards for electronic prior authorization and to promote the use of real-time benefit information to inform clinical decision-making. These efforts aim to streamline the prior authorization process and improve access to care.


The Biden administration’s efforts to address prior authorization requirements have been welcomed by healthcare providers and patient advocacy groups. The American Medical Association has praised the administration’s actions, stating that they will help reduce administrative burdens and improve patient care.


However, some insurers have pushed back, arguing that prior authorization is necessary to control costs and prevent unnecessary treatments. The administration’s proposals have been met with mixed reactions from insurers and other stakeholders in the healthcare industry.

Despite the challenges, the Biden administration remains committed to improving patient access to care and reducing administrative burdens for healthcare providers. By addressing the issue of prior authorization, the administration hopes to make meaningful progress towards these goals.

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