Arthritis Foundation Legislative Position Statements

Prior Authorization

Issue Brief Video

Watch our short video about Prior Authorization, learn about the process and how it can affect people with arthritis.

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Advocate Achievements State Legislation Map

State legislation has focused on prescription drug prior authorization. States in green have enacted legislation that requires the use of an electronic standardized process for prescription drug prior authorization.

The Issue

  • Typically, physicians must fill out a prior authorization form whenever they prescribe a specialty medication or treatment that is restricted or not covered under the insurer's formulary
  • Each insurer uses its own unique form, and physicians may have to spend many hours familiarizing themselves with and completing dozens of forms of varying lengths and complexities
  • As a result, prior authorization typically causes lengthy delays in treatment, thereby restricting a person's access to vital care

The Solution

    1. Establish a single, standardized form for physicians to submit prior authorization requests
    2. Establish electronic systems for the submission of prior authorization requests
    3. Require prior authorization requests to be completed by insurers within 48 hours of submission or receive automatic approval
    4. Once approved, permit authorizations to remain in place for up to 12 months for people with chronic conditions, such as rheumatoid arthritis (RA)
    5. If a prior authorization request is denied, the member must be given clear instructions on how to file an appeal, the information required and deadlines
    6. Provide a process for expedited appeals, especially for urgent care services
    7. Health plans should offer providers/practices at least one physician-driven, clinically based alternative to prior authorization, such as but not limited to “gold-card” or “preferred provider” programs or attestation of use of appropriate use criteria, clinical decision support systems or clinical pathways

Current Trends

  • Patients surveyed by the Arthritis Foundation in 2017 indicated that prior authorization was one of the top two most burdensome insurance issues
  • In 2018, six organizations representing health care providers and health plans released a consensus statement to find opportunities to improve prior authorization programs. This collaboration builds upon the 21 principles outlined above
  • According to a 2018 American Medical Association survey, which examined the experiences of 1,000 patient care physicians, nearly two-thirds (64 percent) report waiting at least one business day for prior authorization decisions from insurers – and nearly a third (30 percent) said they wait three business days or longer
  • More than nine in 10 physicians (92 percent) said that the prior authorization process delays patient access to necessary care; and nearly four in five physicians (78 percent) report that prior authorization can sometimes, often or always lead to patients abandoning a recommended course of treatment
  • A vast majority of physicians (86 percent) believe burdens associated with prior authorization have increased during the past five years

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