Prior authorization processes need significant reform to reduce delays, increase transparency and protect patients.
Springfield, IL – Newly proposed legislation offers a solution to patients frustrated by unneeded delays in their medical care caused by insurance company requirements. Illinois patients often have care delayed or denied because of their health plans’ use of a process called “prior authorization” (PA). Health insurance companies and pharmacy benefit managers use PA to cut costs, requiring health professionals to do extra paperwork before the care they recommend for their patients is approved. The Illinois State Medical Society (ISMS) is pleased to support the Prior Authorization Reform Act (HB 5510 and SB 3822), a comprehensive bipartisan solution that will bring much-needed transparency and streamlining to these prior authorization requirements.
The use of prior authorization has exploded in recent years, but patients and health professionals are often left in the dark about what procedures require prior authorization, and the process itself is frustrating and slow. To make matters worse, PA requirements are often not based on clinically valid criteria, and are administered by individuals who lack relevant qualifications.
“We surveyed over a thousand Illinois physicians on this issue, and they were almost unanimous that their patients are being harmed by prior authorization as it is currently used,” said Illinois State Medical Society (ISMS) President Paul E. Pedersen, MD. “We are seeing longer wait times, rising costs, and patient outcomes that are not as good they should be.”
“These unnecessary and time-consuming prior authorizations raise obstacles for patients, complicate healthcare and waste health professionals’ time with bureaucratic paperwork,” said House Majority Leader Gregory Harris (D-Chicago). “This bill will knock down those barriers for patients.”
Physicians also report long wait times for prior authorization decisions, leaving patients in limbo for days or weeks before they can begin receiving needed care. “Some cancer patients have been left waiting for a month or more before having their treatments approved,” noted Deputy House Republican Leader Tom Demmer (R-Dixon). “It’s heartbreaking, and it’s unacceptable.” The Prior Authorization Reform Act will establish important and consistent timelines so patients don’t have to worry about prior authorization delays causing further damage to their health.
This legislation will also make sure prior authorization requirements are based on medical evidence and administered by qualified individuals. “Only qualified medical professionals should be making determinations about patient care,” added Assistant Senate Majority Leader Linda Holmes (D-Aurora). “That’s why our bill defines who can review and make prior authorization decisions, and ensures that the requirements are based on evidence-based criteria.”
Even when authorization is granted, too often insurance companies later deny payment for medical care they approved. “When an insurance company approves medical care, they’re making a commitment to the patient and the care team,” said Sen. Donald DeWitte (R-West Dundee). “Under the Prior Authorization Reform Act, they’ll no longer be able leave the patient hanging.”
“We don’t want to abolish prior authorization altogether, but change is desperately needed. It’s time to make prior authorization work for the people of Illinois,” concluded Dr. Pedersen. “Our message to Illinois patients is simple: Your care can’t wait!”
A summary of ISMS’ recent physician survey can be found at www.isms.org/YourCareCantWait.
The following organizations support the Prior Authorization Reform Act:
- The American Cancer Society
- The American Nurses Association of Illinois
- The Arthritis Foundation
- The Illinois Association for Behavioral Health
- The Illinois Academy of Family Physicians
- The Illinois Chapter of the American Academy of Pediatrics
- The Illinois College of Emergency Physicians
- The Illinois Section of the American College of Obstetricians and Gynecologists
- The Illinois Society for Advanced Practice Nursing
- The Illinois Society of Eye Physicians and Surgeons
- The Illinois State Medical Society
- The National Organization of Rare Disorders