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Cracking Down on Prior Authorization: The Biden Administration and States Take Action

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Medriva Correspondents
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Cracking Down on Prior Authorization: The Biden Administration and States Take Action

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In an effort to reduce the hurdles faced by patients seeking medical care, the Biden Administration, along with individual states, are implementing new rules to limit 'prior authorization' policies practiced by health insurance plans. These policies, requiring healthcare providers to obtain approval from health insurers before administering certain treatments or medications, have been criticized for creating red tape and causing delays for patients.

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The Biden Administration's Stance

The Biden administration is taking action against insurance plans' prior authorization policies, introducing new regulations for health plans participating in federal programs like Medicare Advantage or the Affordable Care Act marketplace. The administration's crackdown aims to streamline the process and reduce the time patients and doctors spend obtaining approvals for necessary care.

However, the new rules from the Centers for Medicare & Medicaid Services are somewhat limited in scope, prompting doctors and hospitals to support efforts by states to enact their own restrictions on prior authorization.

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States Taking Action

Alongside the Biden administration, states are also taking decisive action. So far, 29 states and the District of Columbia are considering bills designed to limit prior authorization requirements. Notable victories have been achieved in New Jersey and D.C., setting a precedent for other states.

In Missouri, Republican state Rep. Melanie Stinnett has proposed legislation to exempt certain providers from always having to request authorization for care, a process often referred to as 'gold carding'. Under Stinnett's bill, prior authorization requests from medical providers would be reviewed by health plans. Providers approved at least 90% of the time would be exempt from further prior authorization requests for six months.

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Gold Carding Programs

Five states have already passed some form of gold carding program, with an additional 13 states, including Missouri, actively considering similar bills. Gold carding provides a reprieve for providers who have a strong track record of obtaining approvals, reducing their administrative burden and allowing them to focus more on patient care.

Despite this progress, opposition to these policies is prevalent, largely from pharmacy benefit managers and the insurance industry. The fight against prior authorization red tape continues, with the goal of improving patient care and reducing unnecessary administrative burdens on healthcare providers.

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Patients' Challenges

Patients like Christopher Marks, a 40-year-old truck driver from Kansas City, have experienced firsthand the challenges posed by prior authorization. Marks was denied coverage for a medication his doctor prescribed due to prior authorization hurdles, highlighting the need for reform.

The crackdown on prior authorization is a step in the right direction for patient care. By reducing unnecessary bureaucratic hurdles, patients can receive the treatment they need more quickly. As states and the Biden administration continue their efforts, the hope is that the healthcare process will become more efficient, less frustrating, and ultimately, more effective.

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