MSSNY has been working with the American Medical Association and numerous other physician and patient advocacy organizations to address these burdens. In a recent MSSNY survey, nearly 80% of physicians reported that the number of prior authorizations they are required to obtain has increased significantly over the past five years. Even more concerning, one in three physicians reported that prior authorization delays had resulted in serious adverse events for their patients. The administrative burden associated with these requirements is also an important contributor to physician frustration and burnout.
We have been advocating for meaningful reforms at both the state and federal levels. Among other things, MSSNY has supported legislation that would prohibit a health plan from requiring a prior authorization to be repeated once it has already been granted. We have also supported federal legislation designed to shorten the time Medicare Advantage plans have to respond to prior authorization requests.
Although these broader reforms have not yet crossed the finish line, New York State has taken several important steps this year that deserve recognition.
One of the most significant changes is a new requirement that state-regulated health plans cannot impose prior authorization more than once a year for a physician-recommended course of treatment for chronic conditions, including prescription medications. Importantly, that one-year period begins when the health plan approves the treatment. The new law also imposes significant new transparency requirements on health plans regarding which services are the biggest cause of headaches for physician practices and their patients.
New York has long published an annual consumer guide for health insurance coverage which includes cumulative numbers regarding grievances, patient and physician complaints, and appeals of denied services. What was not included was the total number of prior authorizations and denied prior authorizations. Beginning in 2027, New York’s Consumer Guide to Health Insurance will provide information on the number of prior authorization requests submitted, approved, and denied, as well as the number of denials that were appealed and the outcomes of those appeals.
Perhaps equally useful will be the ability to see what services are generating these requirements. Health plans will have to report the 25 CPT codes associated with the highest number of prior authorization requests, including approval rates and information about denials that were subsequently reversed on appeal. For the first time, physicians, patients, and policymakers will have greater visibility into where these requirements are being imposed and how often they are ultimately overturned.
There are other meaningful provisions as well, including improved access to information about prescription formularies and expanded protections allowing patients to continue seeing physicians they trust when they change health plans.
These reforms represent real progress. But I believe we need to be clear: progress is not the same as solving the problem.
Physicians should not have to repeatedly prove that a treatment they have already determined is medically necessary remains medically necessary. We should not need to spend hours navigating an insurer’s bureaucracy to obtain care that our patients need. And physicians treating patients should not have to fight with insurance companies over decisions that should be based on the physician’s knowledge of the patient and the best available medical evidence.
That is why MSSNY will continue to advocate for additional reforms. These include eliminating repeat prior authorizations, establishing meaningful “gold card” programs for physicians whose requests are consistently approved, and ensuring that physicians reviewing prior authorization requests are licensed in New York and practice in the same specialty as the physician providing the patient’s care.
The Governor and Legislature are beginning to recognize what physicians and patients have experienced for years. But lasting change will require continued advocacy. As your MSSNY President, I encourage physicians to continue telling us about the prior authorization requirements that make no sense. If an insurer has created an unnecessary barrier to your patient’s care, MSSNY needs to hear about it. Individual examples may seem small, but collectively they demonstrate the scope of the problem and give us the evidence we need to advocate for change.
We have made progress. Now we need to keep pushing until prior authorization serves its intended purpose, ensuring timely and appropriate care, rather than becoming an impediment to it.
All the best,
Mark J. Adams, MD, MBA, FACR
MSSNY President
