Prior Authorization

Prior authorization approval is required for a wide range of services and medications in 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 34% of physicians reported a detrimental event for a patient due to prior authorization delays.

 

Without reforms prior authorization processes will continue to be an administrative burden on surgeons and an unnecessary barrier to care for patients. The AAOS-endorsed Improving Seniors’ Timely Access to Care Act (H.R. 3173/S.3018) aims to streamline the prior authorization process within MA plans by making it electronic and transparent. The legislation was featured during both Orthopaedic Advocacy Week and the National Orthopaedic Leadership Conference in 2021, resulting in the legislation garnering 85 additional congressional cosponsors.

 

In April, the Office of Inspector General for the U.S. Department of Health and Human services released a damning report that found 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.

 

Please join AAOS in urging your representatives to support the Improving Seniors’ Timely Access to Care Act (H.R. 3173/S.3018). If your representatives have already supported the legislation you will be directed to send them a thank you note and urge them to continue advocating for the bill.