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?

In February, Councilmember Brooke Pinto and eight of her colleagues introduced B25-124, the Prior Authorization Reform Amendment Act of 2023. The bill passed the Council on November 7 and is working its way through the mayoral and Congressional approval process. However, the bill does require funding to cover Medicaid and Alliance plans. Call or email your Councilmembers today and tell them to support fully funding the Prior Authorization Reform Amendment Act.

  • Find your Councilmember here (scroll to the bottom of the page)
  • Tell your Councilmember they should insist the Mayor's budget and/or the Council's budget include funding for B25-124.

DC Physicians - Act Now to Reform Prior Auth

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

On November 7, the DC Council passed B25-124, the Prior Authorization Reform Amendment Act. This bill now moves to the Mayor for her to sign. Our work is not yet done - the bill requires funding to apply the reforms to Medicaid and Alliance patients!

Read B25-124, Prior Authorization Reform Amendment Act, here. Contact your Councilmembers, and learn how below.

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

Read our updated section-by-section analysis here (marked-up version and clean version).

Where is the bill in the legislative process?

The Council passed the bill on November 7. Once the Mayor signs the bill - or it passes without her signature - it goes through the 90 day Congressional review period. We anticipate it will go live for private insurance plans in early spring 2024. However, if the District budget does not fund the parts of the bill pertaining to Medicaid and the Alliance program, these insurance plans will be exempt from the bill. As studies show, Medicaid plans are notorious prior authorization abusers.

What can I do to help fully implement prior auth legislation?

Let MSDC know you want to get involved via our form.

    Contact your Councilmembers and tell them to support funding B25-124 in the budget.

    • Find your Councilmember here
    • Use our talking points for your call, visit, or email
    • Learn the best strategies for advocating on an issue by reading our articles here, here, here, and here.

    Share these links 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

    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. - Primary Care Provider