Fix Prior Authorization Now!
Prior authorization is a requirement to have the insurer approve a treatment before they will cover it. While prior authorization may have a role for services for which a treatment is questionable or where services may be overutilized, its overuse delays needed care, adds to administrative costs, and results in a net cost to population health. Growing prior authorization burdens are also a leading driver of physician burnout.
Why are insurers requiring 75-90% of physicians who are providing the correct care to “jump through hoops” when the required prior authorizations are ultimately approved (based on the data reported by Minnesota’s top five insurers). National data shows that physicians complete on average of 43 prior authorizations per week and that they or their staff spend more than 13 hours a week on getting prior authorization approvals.
While those numbers are shocking, what is worse is the impact prior authorization is having on patient care. According to research, 94% of physicians report that prior authorization has led to care delays, 78% report that prior authorization can and has led to treatment abandonment by patients, and 24% report that prior authorization has led to a serious adverse event for their patients, including 19% reporting that it has led to hospitalization, 13% has led to a life-threatening event, and 7% that it has led to a permanent impairment.
In 2024, the Legislature expanded current Minnesota law that prohibits the use of prior authorization for emergency services to also prohibit prior authorization for non-medication treatment for outpatient mental health, substance use disorder, and cancer care consistent with national cancer-care guidelines. It also prohibits all prior authorization for preventive services recommended by the U.S. Preventive Services Task Force, pediatric hospice services and neonatal abstinence programs.
Additionally, the law now requires that a prior authorization for a chronic condition does not expire, unless the treatment changes. The law also requires utilization review organizations to annually report to the Department of Health how often they require prior authorization, how often they approve the requests, and how often they deny the care.
The reporting requirement is effective starting in 2025. The other changes are effective January 1, 2026. While these changes are a great improvement, they do not apply to most medications. More work is needed to remove these barriers to patients getting the care they need in a timely manner.
#FixPriorAuthNowMN
Tools & Resources
Prior Authorization Issue Brief
The Prior Authorization Burden (Nov/Dec 2014 Minnesota Medicine Article)
Electronic Prior Authorization (ePA)
ePA Recorded Webinar (event took place Dec. 3, 2015)