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As a healthcare professional for nearly 40 years with bedside and administrative roles, a balanced solution to the prior authorization (PA) issue must prioritize both patient safety and timely access to care while maintaining cost containment. Both editorials highlight valid points: Tuffin (IBJ 11/11/2024 PA protects patients, promotes affordability) defends PA as a cost-saving measure that prevents overutilization of healthcare resources, while Pond (IBJ 11/11/2024 It’s past time to put patients over prior authorization) emphasizes how restrictive practices often harm patients through delays or denials of necessary care. A reformed system can address these concerns by focusing on two key areas: exemption of emergency and critical care services from PA requirements, and stricter, time-bound guidelines for non-emergency PA requests with clear justifications.
All emergency services and other critical care interventions—such as treatments for life-threatening conditions or severe pain—should bypass prior authorization entirely. This ensures that patients get the immediate care they need without delays that could worsen their conditions. For non-emergency but urgent cases, a “fast-track” PA option should be created, with a target response time of 24-48 hours to reduce patient pain and distress.
For non-emergency procedures, a legally mandated response time would streamline the PA process. Routine requests should be processed within 48 hours, with a 7-day maximum for non-urgent cases. If an insurer denies a request, it should be required to provide a clear, evidence-based rationale to both the patient and the physician within this timeframe. This addresses transparency concerns and allows patients and providers to understand why a decision was made, potentially avoiding the repeat denials cited by Pond.
To avoid unnecessary bureaucratic overhead, low-cost and low-risk treatments should be exempt from PA requirements, especially if they are well-supported by evidence and have minimal financial impact. Physicians could help develop a checklist for automatic approvals, ensuring that decisions are based on clinical appropriateness rather than cost alone. This would streamline the PA process, especially for high-value care with minimal risk.
As Tuffin notes, electronic PA (ePA) can greatly reduce manual processes, speeding up responses and reducing errors. Insurance companies and healthcare providers should collaborate to digitize the PA process fully. Insurers could also invest in a standardized ePA platform, supported by provider education, to further reduce reliance on outdated fax and phone processes, making the experience faster, more efficient, and more secure.
When coverage is denied, patients and physicians should have access to an immediate peer-to-peer appeal with a specialist in the same field, as suggested by Pond. This ensures that a qualified physician reviews the case based on clinical merits, fostering fairer outcomes for patients and allowing complex cases to get the specialized attention they require.
Through these reforms, PA could become a system that balances patient safety, cost control, and efficient access to care.