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The Need for Prior Authorization Reform

Thu, May 12, 2022 12:29 PM | Babette Atkins (Administrator)

Delayed musculoskeletal care comes at a tremendous cost not only to the patient in terms of quality of life and productivity but to the overall health care system. According to the American Public Health Association, musculoskeletal conditions are a leading cause of disability in the U.S. accounting for more than 130 million patient visits to health care providers annually and the number one reason individuals to see their physician.[1]  

Despite relatively low peer-to-peer denial rates, insurer’s prior authorization and utilization reviews continue to focus on micromanagement aspects of care, typically driven by financial factors.  These techniques are in direct conflict with the patients interests since the results pose unnecessary delays in routine musculoskeletal care and treatment. 

In April 2022, NYSSOS conducted a statewide survey of its membership concerning their experiences in complying with “prior authorization” requirements implemented by insurance companies.

The survey results were consistent, with nearly every respondent reporting that the requirements delayed needed care and often caused preventable harm, debilitation, and pain for patients. Specifically, the survey found:

-    97% of respondents reported that prior authorization fails to achieve its intended purpose of reducing healthcare costs by denying truly ineffective or unnecessary care.

-    88% reported having patients abandon care due to delays associated with prior authorization.

-    94% had patients experience a deterioration of prognosis or quality of life due to prior authorization delays.

-    96% had patients experience sustained or increased pain and/or symptoms due to prior authorization delays.

-    89% had patients experience a delayed return to employment due to prior authorization delays.

> See the complete results

"Gold Card Legislation"
A proposal has been introduced recently in the state Legislature to address this issue. The bill, S.8299/A.9908-A, introduced by Senator Neil Breslin (D-Albany) and Assemblymember John T. McDonald III, RPh (D-Cohoes), would create what is known as a “Gold Card” program that would provide an exemption from prior authorization for health care professionals who receive at least 90% percent approval for a particular health care service over a six-month period. NYSSOS strongly supports this legislation.

 “It ’s time that we confront a growing problem that is present in virtually every treatment room in our state. The proliferation of prior authorization activities is causing unnecessarily delays in care, harming patients and driving avoidable administrative burdens for practitioners. We are calling on state leaders to end the unnecessary patient suffering and debilitation that is directly caused by current prior authorization practices, and we are hopeful that the solution proposed by Senator Breslin and Assemblymember McDonald quickly makes its way through the Legislature and is delivered to the Governor ’s desk.” - John DiPreta, MD, FAAOS, NYSSOS President.


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