Prior Authorization

Prior authorization is used by insurers to approve coverage for medical procedures, treatments, or medications before they are provided. While intended to control costs, prior authorization often leads to administrative burden and delays in patient care. Physicians face time-consuming approval processes, which can delay necessary treatments and impact outcomes. The criteria and processes are often unclear and vary between insurers, causing confusion. ASGE advocates for reforms to simplify and standardize the process, improve transparency, and speed up approvals, reducing the administrative burden on providers and ensuring timely, quality care for patients.

Key Issues

Step Therapy Flexibilities: Advocate for legislation to create common-sense exceptions to step therapy protocols, ensuring more flexible treatment options.

Transparent Gold Card Policies: Support Gold Card legislation that seeks streamline the prior authorization process for providers in a transparent manner.

Improve Prior Authorization Process: Push for the codification and enhancement of CMS regulations to improve interoperability and prior authorization processes in Medicare Advantage plans.

Investigate Utilization Management: Call for an investigation and oversight of insurance companies' utilization management practices, including AI use in prior authorization, to address denials and delays in necessary care.