Combating Insurance Administrative Burdens in New York
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Colleagues:
One of the most persistent challenges for physicians practicing in New York is navigating the administrative burden imposed by health insurance companies. In many regions, a small number of insurers dominate the market, creating an effective oligopoly that allows them to dictate onerous terms of participation, payment, and claims adjudication. These burdens not only strain physician practices but also directly impact patient care.
Physicians routinely encounter delayed payments, retroactive claim denials, extensive prior authorization requirements, unnecessary record auditing, and frequent “down-coding” of services. Such practices can disrupt care delivery, reduce the efficiency of physician offices, and delay necessary treatment for patients. AMA studies have shown that a significant percentage of physicians report adverse patient outcomes linked to administrative delays caused by prior authorization and other insurer-imposed processes.
Specific administrative challenges include:
- Prior Authorization Delays: Patients may experience delays in receiving critical treatments while physicians navigate time-consuming approval processes.
- Retroactive Denials and Down-Coding: Insurers sometimes reduce reimbursement for services after claims are submitted, requiring physicians to appeal and creating financial uncertainty.
- Network Limitations: Physicians may be forced to join large health systems simply to remain in-network, reducing their autonomy and fragmenting care.
- Ghost networks: Healthcare providers have been listed in a health plan’s provider directory who are not actually available to provide care as indicated. These inaccurate directories can delay care and cause high out-of-pocket costs.
- Audits and Dispute Resolution: Frequent audits and the need for independent dispute resolution can divert time and resources away from patient care.
These burdens disproportionately affect smaller, independent practices that lack the administrative infrastructure of larger health systems. When physicians must dedicate significant time to navigate insurer requirements, they have less time to focus on patient care, research, and community health initiatives.
Insurance companies play a vital role in the healthcare system, but their administrative practices should support and not hinder care delivery. MSSNY will, together with our allies, continue to advocate for a system in New York that balances insurer oversight with physician autonomy by ensuring fair reimbursement. protecting the doctor-patient relationship, and promoting a healthcare environment that prioritizes access, efficiency, and quality outcomes. Urge your legislators to support prior authorization reform.
As MSSNY President, I am committed to advancing reforms that ensure physicians can spend their energy where it matters most, caring for their patients.
All the best,
Mark J. Adams, MD, MBA, FACR
MSSNY President
