Prior Authorization Modernization
Prior authorization-with its numerous requirements, ever-changing
criteria, and reliance on outdated technology-is the paramount
administrative challenge faced by physicians and practices. During the
2023 legislative session, the WSMA will introduce priority legislation to
modernize the use of prior authorization to relieve administrative burden,
enhance the health care workforce, and expedite access to care for
2023 Issue Brief: Prior Authorization Modernization
Our ask of the Legislature in 2023
During the 2023 legislative session, the WSMA will ask the Washington
State Legislature to support WSMA priority legislation House Bill 1357 introduced by Rep. Tarra Simmons, D-Bremerton, which would:
Standardize prior authorization requirements across state-regulated
insurance carriers, mandating that carriers utilize electronic systems
rather than fax machines and approving prior authorization requests
within 24-48 hours.
Require insurance carriers to post prior authorization requirements,
evidence, and criteria online and make it available to patients and
physicians upon request to promote transparency.
Ensure that insurance carriers' prior authorization determinations are
made by qualified health care professionals.
Prohibit the use of prior authorizations for services that are routinely
approved, building on 2020 WSMA prior authorization legislation.
Create parity between insurance carriers and physicians in circumstances
where medical malpractice actions may be brought by patients who are
harmed due to delayed or denied care.
Background on prior authorization
When physicians recommend a service or a drug for a patient, health
insurance coverage is often conditioned on prior authorization from a
patient's insurance carrier. Created to control utilization of high-cost
and high-variance services, prior authorization requirements have expanded
exponentially over time and now apply to many commonplace services and
Each insurance carrier has their own prior authorization processes, which
vary from carrier to carrier. Physicians often contract with multiple
carriers, and the lack of standardization makes the process difficult to
navigate and leaves physicians and patients with few options for recourse.
Physicians and patients have reported that the number of services
requiring prior authorization has grown dramatically, with many practices
now dedicating full-time employees that work solely on processing prior
A 2018 consensus statement from physicians, hospitals, and insurance
carriers acknowledged that
prior authorization can be burdensome for all parties involved and
there is need for substantial reform. There have been efforts at the state level to reduce the burden
associated with prior authorization, but its use continues to proliferate.
While a forthcoming federal rulemaking contains elements similar to WSMA's
it will not apply to commercial health plans.
The 2022 Office of the Insurance Commissioner
report to the Legislature on health plan prior authorization
found that the use of prior authorization for some services doubled in the
last year alone. Mental and behavioral health services saw slower
turnaround times and higher denial rates than other services. The report
noted that prior authorization was approved 100% of the time for at least
419 billing codes for health care services.
The impact of inappropriate prior authorization
Washington state physicians regularly report frustration with
inappropriate use of prior authorization as their top concern and top
priority for addressing through legislation. A recent WSMA survey of
outpatient practices in the state found that 89% are experiencing staffing
shortages. Many respondents cited cutting red tape associated with prior
authorization as the most effective way to relieve pressures on the health
Similarly, the American Medical Association recently released
91% of physicians report delays in care due to prior authorization
91% of physicians reported prior authorization creating a significant or
somewhat negative impact to patient outcomes.
75% of physicians report that prior authorization can lead to patient
28% of physicians reported that prior authorization has led to a patient
having a serious adverse event.
Inappropriate use of prior authorization delays and disrupts access to
care for patients, which negatively impacts health outcomes and
substantially drives costs for physicians and health care staff who must
dedicate considerable time to work with the carrier to obtain
authorization for medically indicated care, creating unnecessary barriers
for all as most prior authorizations are eventually approved.
Contact WSMA Director of Government Affairs Sean Graham at
firstname.lastname@example.org or 360.259.4184.
Further reading in prior authorization