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“Should Indiana prohibit prior authorization in health care?”
Health insurance plans are committed to helping Americans access safe, evidence-based care, and to protecting patients from low-value and inappropriate services so coverage is as affordable as possible. While it is limited and targeted, prior authorization plays an important role in ensuring health plans and their provider partners work together to deliver on that commitment and help patients receive high-quality care in the highest-value setting.
Health plans use prior authorization selectively, focusing on clinical areas prone to extreme variation in cost or misuse that can harm patients or saddle them with unexpected and costly medical bills. Plans are also waiving or reducing prior authorization for certain patients to promote continuity of care and are increasingly waiving or reducing prior authorization for providers who have a track record of delivering evidence-based care.
At a time when experts agree that roughly one-quarter of health care spending is wasteful at best and harmful at worst, prior authorization provides a vital check and balance to improve both safety and affordability for patients while also promoting the sustainability of our health care system.
Health plans are also leading the way to further simplify and improve prior authorization for patients and providers. For example, health plans have made significant investments in electronic prior authorization to streamline requests, shorten decision times and lower administrative burdens on providers and plans alike.
Ensuring this important patient protection tool is expeditious and seamless is a two-way street, and both plans and providers must do their parts. Unfortunately, in our digital age, far too many providers still insist on submitting requests via fax machines and phones, rather than real-time digital tools that are more secure, more accurate, more accountable and more cost-effective. In fact, six in 10 prior authorization requests for medical services and nearly four in 10 prior authorization requests for prescription drugs are still submitted manually. This reliance on long-outdated and error-prone manual processes results in uncertainty and delays for patients and creates costly and time-consuming administrative burdens for all involved.
Some powerful interests distort both the purpose and the prevalence of prior authorization and aggressively lobby to undermine basic quality and affordability protections—while simultaneously resisting common-sense reforms to opaque and deceptive medical billing practices. This is an agenda that would lead to soaring health costs and even more wasteful care.
We urge policymakers to objectively evaluate the important role targeted prior authorization plays to support patient safety, better health outcomes and affordability.•
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Tuffin is president & CEO of AHIP, formerly known as America’s Health Insurance Plans. Send comments to ibjedit@ibj.com.
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As a healthcare professional for nearly 40 years with bedside and administrative roles, a balanced solution to the prior authorization (PA) issue must prioritize both patient safety and timely access to care while maintaining cost containment. Both editorials highlight valid points: Tuffin (IBJ 11/11/2024 PA protects patients, promotes affordability) defends PA as a cost-saving measure that prevents overutilization of healthcare resources, while Pond (IBJ 11/11/2024 It’s past time to put patients over prior authorization) emphasizes how restrictive practices often harm patients through delays or denials of necessary care. A reformed system can address these concerns by focusing on two key areas: exemption of emergency and critical care services from PA requirements, and stricter, time-bound guidelines for non-emergency PA requests with clear justifications.
All emergency services and other critical care interventions—such as treatments for life-threatening conditions or severe pain—should bypass prior authorization entirely. This ensures that patients get the immediate care they need without delays that could worsen their conditions. For non-emergency but urgent cases, a “fast-track” PA option should be created, with a target response time of 24-48 hours to reduce patient pain and distress.
For non-emergency procedures, a legally mandated response time would streamline the PA process. Routine requests should be processed within 48 hours, with a 7-day maximum for non-urgent cases. If an insurer denies a request, it should be required to provide a clear, evidence-based rationale to both the patient and the physician within this timeframe. This addresses transparency concerns and allows patients and providers to understand why a decision was made, potentially avoiding the repeat denials cited by Pond.
To avoid unnecessary bureaucratic overhead, low-cost and low-risk treatments should be exempt from PA requirements, especially if they are well-supported by evidence and have minimal financial impact. Physicians could help develop a checklist for automatic approvals, ensuring that decisions are based on clinical appropriateness rather than cost alone. This would streamline the PA process, especially for high-value care with minimal risk.
As Tuffin notes, electronic PA (ePA) can greatly reduce manual processes, speeding up responses and reducing errors. Insurance companies and healthcare providers should collaborate to digitize the PA process fully. Insurers could also invest in a standardized ePA platform, supported by provider education, to further reduce reliance on outdated fax and phone processes, making the experience faster, more efficient, and more secure.
When coverage is denied, patients and physicians should have access to an immediate peer-to-peer appeal with a specialist in the same field, as suggested by Pond. This ensures that a qualified physician reviews the case based on clinical merits, fostering fairer outcomes for patients and allowing complex cases to get the specialized attention they require.
Through these reforms, PA could become a system that balances patient safety, cost control, and efficient access to care.