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PA Patients and Providers Rally Together for Prior Authorization Reforms

May 01, 2019

Yesterday in Harrisburg, HAP joined patients and other providers to introduce legislation reforming the insurance practice of requiring prior authorization for medical care. Unfortunately, current prior authorization processes can delay the timely delivery of appropriate, medically necessary care.

Prior authorization is the insurance practice of requiring a health care provider to obtain advance approval from a health plan before a specific procedure, service, device, supply, or medication can quality for coverage by that plan when that care is delivered to the patient. Other terms used by health plans for this process include “preauthorization,” “precertification,” “prior approval,” “prior notification,” “prospective review,” and “prior review.”

Health insurance plans instituted the use of prior authorization requirements to keep health care costs under control. But providers have continued to experience an increasing number of scenarios where prior authorization has caused significant delays in the delivery of timely and appropriate care for patients for commonly prescribed drugs and services.Andy Carter remarks at prior auth pressor

HAP supports House Bill 1194, sponsored by Representative Steven Mentzer (R-Lancaster), to protect against inappropriate prior authorization practices. These practices lead to delays in patients receiving medically necessary care and create significant administrative burdens for providers, burdens that also detract from patient care.

Additionally, inappropriate use of prior authorization has been shown to increase health care costs for businesses, consumers, and government payors, and also has a significant impact on quality of care. A 2013 study projected the cost to primary care physicians of obtaining prior authorization to be over $3,000 per physician. A 2018 study estimated the cost to be $83,000 per physician per year. These costs create a more costly health care system for all. 

“While health care costs are top of mind for everyone, the impact on quality of care is even more concerning,” said Andy Carter, HAP president and chief executive officer. “A survey of health care practitioners shows that 92 percent report prior authorization having a negative impact on patient clinical outcomes. That is just unacceptable and our patients deserve better.”  

HAP thanks Representative Mentzer for his efforts to address prior authorization burdens and his recognition of the importance of timely care. House Bill 1194 is currently seeking co-sponsors for support of the legislation.

For more information, please contact Kate Slatt, HAP’s senior director, innovative payment and care delivery, or Stephanie Watkins, HAP’s vice president, state legislative advocacy. 

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