March 2025 President’s Message

MSSC needs your help on prior-authorization reform

by Jany Moussa, MD —

MSSC asked its members in a survey last month what challenges they or their practices face. One recurring answer was “prior authorization.”

“So many things that used to not need ap­proval now do,” one physician wrote. “It’s burden­some, time consuming and, therefore, expensive. My staff spend a ridiculous amount of time on the phone.”

Amen to that.

It is maddening how much time my staff spends getting ap­proval of standard procedures. It’s especially infuriating because virtually all these authorizations are eventually approved (as they should be). Why waste everyone’s time and money?

MSSC is trying to tackle this problem at both the federal and state levels.

MSSC signed on last year as a supporter of the Improving Seniors’ Timely Access to Care Act. This bipartisan federal legisla­tion, which is cosponsored by Kansas Sens. Roger Marshall, MD, and Jerry Moran, seeks to streamline the prior-authorization process for beneficiaries of Medicare Advantage plans.

I and several other MSSC physicians were in Washington, D.C., last month and spoke to Sen. Marshall about the legislation. He hopes that applying the reform first to MA plans will lead to wider reform. The bill has majority support in both the House and Senate; however, Sen. Marshall was uncertain about its prospects (there is a lot of uncertainty in D.C. these days).

MSSC and the Kansas Medical Society also have pursued state reforms that would apply to private insurance companies, but it has been a difficult go. MSSC member Jay Gilbaugh, MD, led a push several years ago. KMS brought up the issue again two years ago.

It is time to try again.

I’m interested in Kansas creating something like the Gold Card program in Texas and several other states. Under the Texas program, a physician qualifies for a preauthorization exemption (a “gold card”) for a particular healthcare service if the insurer has approved at least 90% of the preauthorization requests submitted by the provider for that service during a defined six-month evalu­ation period.

In other words, if you prove you are a responsible physician, you don’t have to keep jumping through the same old hoops

Insurance companies in Kansas vigorously opposed this in the past. But there are some new signs of hope.

UnitedHealthcare launched its own national Gold Card pro­gram last October. To be eligible, a physician must be in network for at least one UHC plan, meet a minimum annual volume of at least 10 eligible prior authorizations each year for two consecutive years across Gold Card-eligible codes, and have a prior-authori­zation approval rate of 92% or more across all Gold Card-eligible codes for each of the review years.

If UHC was willing to do this on its own, would other carriers do the same? We intend to ask.

These programs don’t solve all the problems. Insurers may deliberately make the eligibility requirements confusing or difficult to meet. For example, two years after Texas passed its law, only 3% of physicians and healthcare professionals met the Gold Card eligibility threshold.

Still, we need to keep pushing.

It is too late this current legislative session to tackle this issue, but I want to lay the groundwork for a potential multiyear effort. One way you can help is by sending MSSC an example or two of the problems or frustrations you have experienced with prior authorization. Was a patient’s health put at risk or harmed by un­necessary prior-authorization delays? Let us know.

Prior-authorization reform is difficult. But with your help, maybe we can finally break through and get some commonsense relief.

Send us your horror stories

We have all experienced prior-authorization roadblocks by private insurance companies that led to unnecessary and poten­tially harmful delays in care. Send us an example or two that we can share with lawmakers (citing the specific insurance company, if possible). Also, how much time do you and your staff spend on prior authorizations? Email MSSC at denisephillips@med-soc.org. Thank you for your help.