Prior Authorization

Prior authorization approval is required for a wide range of services and medications in traditional Medicare, Medicare Advantage (MA) and commercial plans. While intended to control costs, this process can delay or deny necessary medical care and negatively influence patient outcomes. A recent American Medical Association survey found that 34% of physicians reported a detrimental event for a patient due to prior authorization delays.

In April 2022, the Office of Inspector General for the U.S. Department of Health and Human services released a report which found that MA plans inappropriately denied up to 85,000 prior authorization requests in 2019, and nearly 20% of reimbursement payments were denied despite meeting Medicare coverage rules. Reforms to the prior authorization process in MA plans is made even more timely as MA enrollment surges, with over half of Medicare beneficiaries expected to be enrolled in an MA plan by 2025.

The Gold Card Act seeks to provide a federal solution, modeled after Texas' successful gold card law, to streamline and improve the prior authorization process. This legislation would exempt physicians, who in the previous year received approval for at least 90% of their prior authorization requests, from the prior authorization approval process for MA by issuing a “gold card." The Gold Card status could be revoked if a review found that less than 90% of claims approved would otherwise be denied​.

In the 117th Congress, the Improving Seniors’ Timely Access to Care Act, which is supported by more than 500 organizations, sought to directly improve flawed prior authorization processes within MA. The bill passed on a voice vote in the U.S. House of Representatives and garnered the support of 52 cosponsors in the U.S. Senate.

In the wake of this legislation, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule in December 2022 that included many of the same improvements, such as requiring certain payers to implement an electronic prior authorization process, shorten the timeframes to respond to prior authorization requests, and establish policies to make this process transparent. AAOS submitted comments in response to this rule and is now advocating that CMS quickly finalize and implement these requirements.