Reform Prior Auth


Video: How You Can Advocate For Prior Auth Reform - In Minutes




MSDC's Prior Auth Program, January 2022




A physician's story about prior auth




A patient's story about prior auth



Patients Deserve Medical Care Without Corporate Interference

Who do you trust to treat you - your physician or an insurance company?

Prior authorization prevents patients from receiving the care they need. Rather than let medical professionals treat patients, corporate interests and insurers insert themselves into medical decisions without exams, medical history, or seeing a patient.

Prior authorization FAQ for patients

What is prior authorization? defines prior authorization as, "A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost."

Basically, if your doctor or medical provider has prescribed you a treatment to help you, and it has been held up by the insurance company to see if it is really necessary, you've been impacted by prior authorization.

Why do insurers use prior authorization if it negatively impacts my care?

Cigna describes prior auths like this: "The prior authorization process gives your health insurance company a chance to review how necessary a medical treatment or medication may be in treating your condition. For example, some brand-name medications are very costly. During their review, your health insurance company may decide a generic or another lower-cost alternative may work just as well in treating your medical condition."

Here's the thing: this isn't the case. Data by the American Medical Association shows that physicians report that 93% of cases requiring prior auth delay care (i.e., you don't get the treatment you need in a timely manner). Physician also report that 3 in 10 times a prior auth is used by an insurer, the decision to do it has no clinical basis (i.e., there's no medical reason for the delay).

What could happen to me if I'm subject to prior authorization?

According to the AMA physician survey, you stand a chance of not getting the treatment you need and facing escalating medical issues. Physicians share that 34% of prior auth cases lead to adverse medical effects for their patients (i.e., your condition gets worse). In 82% of cases, according to the survey, the prescribed treatment may be abandoned due to the prior authorization!

This quote from Dr. Brian Barnett puts it best: "Being regularly compelled by insurers to reconsider and justify treatment decisions we have made in our patients’ best interests, providers are increasingly wondering who’s actually doing the prescribing — us or people with no medical training who know our patients’ names only because they’re reading them on computer screens?"

What can I do to protect myself from prior authorizations?

The DC Council is considering a bill to reform the prior authorization and ensure that if they are issued there are protections for patients and their care. The bill, B24-655 (seen here), is under review by the Committee on Health. Call or email your Councilmembers today and tell them to support the Prior Authorization Reform Amendment Act.

DC Physicians - Now Is Your Time To Fight for Reform

Tell the DC Council prior auth reform is needed for your patients

The DC Council is considering legislation to regulate prior authorizations and make it harder for payers to delay or change your patients' treatments. Your actions today could save your patients' health and your office time.

Read B24-655, Prior Authorization Reform Amendment Act, here.

What would the bill do to help my patients?

The bill would:

  • Lay out minimum length that a prior auth is considered valid
  • Set qualifications for payer personnel to make prior auth determinations
  • Prohibit utilization review based on cost and only allow it for medical reasons
  • Require utilization review honor a previous prior auth for the first 60 days of coverage
  • Require payers to make prior auth statistics publicly available
  • and more
Where is the bill in the legislative process?

Councilmember Mary Cheh, with colleagues Charles Allen/Anita Bonds/Vincent Gray/Janeese Lewis George, introduced B24-655 in February. The bill is before the Committee on Health. MSDC is pushing for the bill to have a hearing and a mark-up. The bill must have a hearing, mark-up, and be passed by the Council before the end of the year.

What can I do to help pass B24-655?

We need your help to pass this legislation! Here's how you can get involved:

Let MSDC know you want to get involved via our form

Contact your Councilmembers and tell them to support the bill

Share this link and information with your colleagues

What DC physicians say about prior auth

My patient was denied access to a particular birth control pill she had been on successfully before, and my office was told she needed to try and fail on 5 different generic pills before she could be approved. - OB/GYN

During every rotation of clinical training, I have spent hours ensuring my patients would have coverage for needed services. These are hours I could have spent studying or providing care while learning, but instead it was mostly wasted on hold with insurance carriers. - Howard medical student

Prior authorizations can be so onerous that they effect how many new patients I am able to take into my practice.  Knowing that each time I see a new patient I might need to spend an amount of time equal to the visit itself haggling with an insurance company means that I decrease the number of patients that I can help in order to manage (or avoid) the paperwork. - Psychiatrist

I have had patients require life saving medications, but been unable to use them due to prior authorization delays. For example, I had a patient require a long acting insulin that he wasn't able to obtain due to prior authorization delays, and then had to be admitted to the hospital for a severe complication called Diabetic Ketoacidosis for 4 days - all of which could have been prevented if he could get his insulin. - Internal medicine physician

I spent 90 minutes of time with the prior authorization department and an additional 30 minutes with the pharmacy and the patient all because they changed their formulary and would not "grandfather him in". - Psychiatrist

A patient with complex PTSD from severe childhood sexual abuse has insomnia. She has been tried on multiple medications for her insomnia... For 2 years she has been sleeping well on generic zaleplon 20 mg. The insurance company has a quantity limit of one capsule per day. The FDA has approved a dosage range of 5 mg to 20 mg. It only comes in 5 and 10 mg size capsules so in order to get the dose that works of this generic medication within the range the FDA has approved she needs two capsules per day. I spent 3 days of back and forth with the insurance company giving them information they already had on file from last year to get the approval for the two pills per day.  - Psychiatrist