Prior Authorization Should Never Stand Between Seniors and Care

For many Americans across the nation, navigating approvals for necessary health care can feel as challenging as the illness or condition they are treating. 

At the center of many of these frustrations is the prior authorization process, which remains the number one burden identified by health care providers.

Prior authorization is a tool to ensure that patients receive efficient and necessary treatment while spending insurance dollars appropriately. While valuable, this tool has, in practice, been often abused by health insurers. Perhaps most notably, the final decision about your care often isn’t made by your provider — it’s by your insurance company. At times, “prior auth” leads to burdensome paperwork for physicians and hospital teams while slowing timely care for vulnerable patients.

The goals are simple: to increase transparency for both the patients and providers, to set clear timelines for decisions, and to strengthen protections for beneficiaries. Our current system relies on outdated fax machines, phone calls, and inconsistent procedures. By replacing these with a more efficient electronic process, we can reduce unnecessary delays and ensure patients receive the timely, necessary care they need. 

Patients and providers around the nation use the prior authorization process every day. Streamlining the process for Medicare Advantage will especially help rural communities, like those throughout Pennsylvania’s 16th Congressional District, where such plans are growing in popularity.

In recent years, rural hospitals have seen more than double the growth in Medicare Advantage use as their urban peers, an American Hospital Association report found. But the delays and denials created by prior authorization barriers have serious consequences for patients, providers, and hospitals — 81% of rural clinicians report that such barriers reduce the quality of care; nearly 80% report higher administrative burden; and 86% say they’re seeing negative effects on patient outcomes.

Many rural hospitals, physicians, and health systems already face a variety of obstacles every day.  They depend on timely approvals, reimbursements, and efficient administrative processes — without frustrating red tape — to continue serving patients close to home. By reforming prior authorization in Medicare Advantage, we can help reduce administrative burdens across the board, allowing providers to spend valuable time focused on patient care rather than paperwork. With that, patients throughout the community — not just Medicare Advantage beneficiaries — will benefit from a stronger, more stable health care system.

Health care should be centered on patients, not bureaucracy. Seniors who have earned their Medicare benefits deserve access to the care they need when they need it. Enrolling in a Part C “Advantage” plan should be just that: an advantage. At the same time, physicians and hospitals deserve systems that support personable patient care.

The strong bipartisan support for the Improving Seniors' Timely Access to Care Act demonstrates that this is not a partisan issue. It is commonsense reform that puts patients first, strengthens rural health care, and modernizes an outdated process that is no longer serving Americans as intended.

By streamlining the Medicare Advantage prior authorization process, we will not only heal patients, but also heal a broken system that for too long has put paperwork over people.

U.S. Rep. Mike Kelly (PA-16) is the sponsor of the Improving Seniors' Timely Access to Care Act. Nicole Stallings is president and CEO of The Hospital and Healthsystem Association of Pennsylvania.