Relieving Administrative Burden: How Surgeons, Washington, and Industry Partners Are Working to Reform Prior Authorization

Recent developments in the healthcare industry’s ongoing struggle with prior authorization (PA) requirements have revealed a significant shift in the landscape. Strong bipartisan support, new efforts from the insurance industry, and the emergence of hospitals as powerful new allies are helping to build momentum for reform.

Legislative progress: Improving Seniors’ Timely Access to Care Act
First introduced in 2019 during the 116th Congress, the Improving Seniors’ Timely Access to Care Act aims to enhance the Centers for Medicare & Medicaid Services’ (CMS’) Advancing Interoperability and Improving Prior Authorization Processes rule that was finalized in January 2024. The regulation requires Medicare Advantage plans to convey PA determinations within 72 hours for expedited requests and 7 days for standard requests. Medicare Advantage plans must also provide a specific reason for denying a PA appeal and report approval and denial metrics as part of new transparency requirements.

The bill was reintroduced in 2021 during the 117th Congress and, most recently, in June 2024 by a bipartisan group of lawmakers in the 118th Congress: Senators Roger Marshall, MD (R-Kansas); Kyrsten Sinema (I-Arizona); John Thune (R-South Dakota); and Sherrod Brown (D-Ohio), along with Reps. Mike Kelly (R-Pennsylvania); Suzan DelBene (D-Washington); Larry Bucshon, MD (R-Indiana); and Ami Bera, MD (D-California).

The legislation gained remarkable support, with more than 400 organizations endorsing it, including AAOS. Unlike the previous iteration introduced during the 117th Congress, which faced challenges due to projected costs, the most recent version of this bill has minimal financial impact. Despite enjoying majority bipartisan support in both the House and the Senate, Congress ultimately failed to advance the bill. However, AAOS expects this legislation to be introduced again in the coming months.

The bill includes several key provisions designed to improve PA in Medicare Advantage:

• implementation of an electronic PA process
• requirement for qualified medical personnel to review authorization requests
• reduction in PA for routinely approved services
• mandatory reporting from Medicare Advantage plans on authorization delays and denials
• protection against PA requirements for medically necessary services during preapproved surgeries

The urgency for this reform is underscored by troubling statistics. A 2022 report from the Department of Health and Human Services Office of Inspector General revealed that Medicare Advantage plans inappropriately denied numerous requests for covered care. In a survey conducted by the American Medical Association, 35 percent of physicians reported serious adverse events—including hospitalization, disability, permanent bodily damage, or death—due to PA issues, and 88 percent described the associated burden of PA as high or extremely high. Legislation and regulation are intertwined, so meaningful reform also requires involvement from the executive branch, and the White House and CMS are crucial advocates for change.

A new ally emerges: hospitals
Although orthopaedic surgeons have long grappled with PA requirements, the issues extend far beyond surgical procedures, affecting everything from basic medication access to critical oncology treatments. Perhaps the most significant recent development is the emergence of major industry stakeholders, such as the American Hospital Association, going on the record with Capitol Hill to join in the fight against burdensome PA processes. This shift comes as hospitals face increasing challenges, including:

• post-procedure lookbacks and “clawbacks,” where insurers retroactively withdraw payment for previously approved procedures
• requirements to provide detailed information that may exist in physician offices but not in electronic health records
• direct financial impact as employers of physicians affected by PA requirements

Current insurance industry response
Recent initiatives, such as UnitedHealthcare’s “gold card” program, have shown both progress and limitations. Although the program allows qualifying practices to streamline approval for certain medical procedures that are commonly approved (the gold card), it notably excludes major orthopaedic procedures such as total knee replacements, total hip replacements, rotator cuff repairs, and spine surgeries, providing limited value to specialist physicians.

Looking ahead
AAOS continues to value PA reform as a top-tier policy issue in its Unified Advocacy Agenda, with its Office of Government Relations actively pursuing both legislative and regulatory solutions. AAOS’ goal is to help members spend more time with patients and less time with paperwork.

The evolution of the PA battle suggests that success will require a united front among healthcare practitioners, hospitals, and advocacy organizations. With hospitals now experiencing direct impacts from PA policies and continued bipartisan support for reform, the momentum for meaningful change appears to be building. The challenge will be maintaining this momentum while finding workable solutions that satisfy all stakeholders and prioritize patient care.

Jordan Alyssa Heyman, MBA, is senior director of policy and regulatory affairs at AAOS. She has 10 years of experience in health policy and advocacy, including prior positions with the House of Representatives, a large health insurer, and a business trade association.

Erin K. Morris is a government relations director and federal registered lobbyist for AAOS’s Office of Government Relations.

References

1. Anderson KE, Darden M, Jain A: Improving prior authorization in Medicare Advantage. JAMA 2022 Oct 18;328(15):1497-8.
2. American Medical Association: 2023 AMA Prior Authorization Physician Survey. Available at: https://www.ama-assn.org/system/files/prior-authorization-survey.pdf. Accessed Feb. 7, 2025.