The Problem

Health plan overuse of prior authorization as a blunt cost-control tactic has placed health plans profits over patient safety and intruded on physicians’ ability to make health care decisions that best serve their patients’ interests. Patients and their physicians are forced to wade through red tape, delays and denials, all while their medical conditions worsen. 

Nearly one in four (24%) of physicians say that prior authorization has led to a serious adverse event – such as hospitalization, permanent bodily damage, and even death – for a patient in their care. Physicians and medical professionals are also spending hours a week on unnecessary paperwork – time they could otherwise be spending with patients. On average, physician practices complete 43 prior authorizations per week, and physicians and their staff spend nearly two working days out of the week completing prior authorizations. 

The Solution: CMA’s Prior Auth Legislative Package

CMA’s legislative prior authorization reform package would implement common-sense reforms to streamline the prior authorization processes, expedite critical care for patients and free up physicians’ time to focus on patients, not paperwork. The legislative package includes:

• AB 510 (Addis): Requires that appeals of prior authorization denials be performed by a provider of the same or similar specialty. This will help ensure that providers can discuss prior authorization denials with a professional peer who understands the recommended treatment and underlying condition. 
• AB 539 (Schiavo): Extends the validity of an approved prior authorization to one year (current industry standard is between 60-90 days). This will provide patients with a longer window of time to receive medically necessary care and avoid cumbersome prior authorization review (and ultimately appeal) processes.
• AB 512 (Harabedian): Requires health plans to respond to urgent prior authorization requests within 24 hours and respond to nonurgent requests within 48 hours. Currently, health plans have 72 hours for urgent and five days for nonurgent requests. This change will ensure more patients can receive care in a timely fashion, consistent with the urgency of their condition or can swiftly appeal any denials, if necessary.  
• SB 306 (Becker): Requires health plans to remove the requirement for prior authorization from any service that they approve more than 90% of the time. This will reduce the overall volume of prior authorization requests and ensure that patients can receive the care they need with minimal delay and physicians can spend more time focusing on patient care.