Prior Authorization Process Problems and New State Solutions

Think of prior authorization like a traffic light in the middle of an emergency. Doctors know where to go and what you need—maybe it’s a test, a medication, or urgent treatment—but everything comes to a stop until the insurance company turns that light green. Prior authorization is a specific utilization management method leveraged by insurance payers to control unnecessary spending. Insurance companies always want you to receive authorization before administering certain tests, medications, and treatments. 

But today, it’s causing real harm. Patients are stuck waiting. Doctors are drained. Treatment delays due to PA formalities often cause patients’ lives to hang in the balance of uncertainty. The system meant to protect is now often blocking care. The good news? Some states are finally changing the PA system. They’re rewriting the rules to make prior authorization faster, simpler, and more focused on patients. These reforms may finally put care back in the fast lane. 

Here are the reasons why the prior authorization process needs to change: 

Why Does The Prior Authorization Process Need To Change? 

Insurance providers introduce new rules and paperwork each year, making it more challenging for you to keep up with the changing requirements. The growing demand for prior authorization often delays patient care. Patients may wait days for urgent tests or treatments, while providers lose valuable time on forms, faxes, and follow-ups. On top of that, your PA often gets denied without any clear reason, leaving your patients without the needed care. 

According to the American Medical Association (AMA): 

• 94% of physicians say prior authorization causes care delays.
• 24% say it has led to serious harm to patients.

That’s why reform is urgent. And now, several states are taking action. 

States Leading the Push for Reform 

Let’s look at the states making bold moves to fix prior authorization.   

1. Texas: Gold Card Law

Texas came up with a new House Bill called 3459, which is also known as the Gold Card Act.” This rule allows doctors with a 90% prior authorization approval rate for certain medical services over 6 months to avoid prior authorization in Texas for those specific services. Health plans can always check a doctor’s gold card status two times a year, but there should be a notice period of 25 days. The peer review must be conducted by a Texas-licensed physician in the same or a similar type of facility. This law reduces paperwork, cuts delays, and helps patients get care faster. It also rewards doctors who provide quality care. HB 3459 has influenced other states to consider similar laws to make the healthcare process smoother and more efficient. 

2. Ohio: Prior Authorization Streamlining

Ohio also made a significant change to its rules of prior authorization in 2018. Insurers must now respond to urgent prior authorization requests in 48 hours and non-urgent ones in 10 days. They also have to explain denials clearly and provide electronic forms for easy submission. In 2023, for prior authorization Ohio proposed a new “Gold Card” program that would let providers with an 80% approval rate skip prior authorization for certain services. This would cut down paperwork, prior authorization delays and speed up patient care. Though not yet a law, the program aims to reduce delays, improve clarity, and make the process easier for everyone.  

3. Colorado: Reducing PA Burdens

Starting January 1, 2024, Colorado’s SB22-078 lets insurance companies skip prior authorization for “qualified providers” who have been in the plan for 12 months and have a 95% approval rate. These providers may get exemptions, incentives, or other programs to reduce delays and paperwork. Providers are reevaluated yearly to keep these benefits. The goal is to make prior authorization in Colorado simpler, cut admin work for doctors, and help patients get care faster. Colorado is focusing on fairness and transparency.   

4. Delaware: Tightening the Timelines

Delaware is changing how prior authorization works as it passed a new law, SB 10, in 2023. It says insurers must decide on urgent requests in 24 hours. For non-urgent ones sent electronically, they have 4 days. Insurers must also use electronic systems. If they deny a request, they must explain why with medical reasons. These steps help reduce delays, give faster answers, and use better technology. 

5. Michigan: Reform for Behavioral Health

In 2022, Michigan changed its prior authorization rules for behavioral health care. The new law limits PA for mental health therapy and substance use disorder services. These changes were made because delays in care can be harmful. Now, patients get faster access to therapy, face fewer hurdles for addiction treatment, and mental health providers get more support. Michigan is helping one of the most vulnerable patient groups. 

6. Illinois: Medicaid Reform

Illinois has already changed how prior authorization works for Medicaid patients. Every Medicare Managed Care plan must adhere to the same prior authorization rules in Illinois. Insurance companies must report how many requests they approve or deny. They also need to use simpler electronic systems. These changes mean less confusion for doctors, easier tracking of delays and denials, and better accountability. Illinois is making the process faster and more organized. 

The truth is that most healthcare practices often lack a dedicated team of PA professionals who can handle all the nuances of the prior authorization process. Fortunately, prior authorization services from a well skilled revenue cycle management company can be the perfect help for medical practices.   

Know How A Prior Authorization Company Can Help You:  

Expert PA professionals can cut delays by handling forms, tracking requests, and using electronic tools. They reduce paperwork, follow up with insurers, and explain denials. This saves doctors time, speeds up approvals, and helps patients get care faster, especially in states now pushing for reform. Looking to solve your prior authorization woes, it’s time to get your authorization checked from professional outsourcing prior authorization company.