ASCRS GOVERNMENT RELATIONS
Prior Authorization Policies
Unwarranted prior authorization requirements put vulnerable patients at risk for delayed or denied services that could save their sight. ASCRS continues to urge CMS to use its oversight authority to ensure that Medicare Advantage plans are not inappropriately delaying or denying beneficiaries access to medically necessary cataract surgery. Additionally, ASCRS supports legislation that would reduce the burdens associated with prior authorization.
Prior authorization is a cumbersome process that requires physicians to obtain pre-approval for medical treatments or tests before rendering care to their patients. The process for obtaining approval is lengthy and typically requires physicians or their staff to spend the equivalent of two or more days each week negotiating with insurance companies — time that would better be spent taking care of patients. Patients experience significant barriers to medically necessary care due to prior authorization requirements for items and services that are eventually routinely approved. Recent surveys of specialty physicians have found that:
- Nearly 90% have delayed or avoided prescribing a treatment due to the prior authorization process;
- 95% report that this increased administrative burden has influenced their ability to practice medicine;
- 82% state that prior authorization either always (37%) or often (45%) delays access to necessary care;
- Prior authorization causes patients to abandon treatment altogether, with 32% reporting that patients often abandon treatment and 50% reporting that patients sometimes abandon treatment;
- Nearly two-thirds report having staff who work exclusively on prior authorizations, with one-half estimating that staff spend 10-20 hours/week dedicated to fulfilling prior authorization requests and another 13% spending 21-40 hours/week; and
- Ultimately, the majority of services are approved (71%), with one-third of physicians getting approved 90% or more of the time.
ASCRS supports the bipartisan Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018) that would increase transparency and streamline prior authorization in the Medicare Advantage (MA) program by:
- Establishing an electronic prior authorization program that meets specified standards, including the ability to provide real-time decisions in response to requests for items and services that are routinely approved;
- Annually publishing specified prior authorization information, including the percentage of requests approved and the average response time; and
- Meeting other standards, as set by CMS, relating to the quality and timeliness of prior authorization determinations.
ASCRS has also signaled support for the Getting Over Lengthy Delays in Care As Required by Doctors (GOLD CARD) Act of 2022 (H.R. 7995) which would ensure Medicare Advantage plans are not inappropriately delaying or denying beneficiaries’ access to medically necessary surgery by establishing a prior authorization waiver for a physician who had a 90% approval rate of their previous year’s prior authorization submissions.