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Prior Authorization: A State-Level Perspective

By Prior AuthorizationNo Comments

Grassroots advocacy has played a crucial role in addressing the burdensome and increasingly complex prior authorization processes that have frustrated neurosurgery patients, leading to unnecessary delays in care, worsening neurological deficits, and denial of essential services. Neurosurgeons have faced overwhelming administrative tasks that are both time-consuming and require additional staffing, significantly increasing overhead costs. State governments are uniquely positioned to collaborate with grassroots efforts in shaping advocacy initiatives and developing state legislation to address these challenges.

A common question is why both federal and state legislation are necessary to drive progress. The simple answer is that each plays a unique role. While the federal government influences prior authorization through national programs like Medicare, states regulate private insurance. States have more detailed and diverse rules regarding prior authorization, particularly for Medicaid and state-regulated health insurance plans. Each state establishes its own laws or regulations on how insurers must operate, and the degree of regulation can differ significantly from one state to another. Additionally, state law is strengthened by state-level insurance commissioners, who oversee prior authorization processes for private insurers licensed in the state. These commissioners have the authority to enforce state laws and investigate complaints regarding prior authorization denials or delays.

By working together, both the federal and state levels of government can improve the system for all patients and physicians. States are particularly well-positioned to advance these efforts on a local level.

As of 2024, ten states have passed legislation reforming the prior authorization process, with more states actively considering similar measures. These states include Colorado, Illinois, Maine, Maryland, Minnesota, Mississippi, Oklahoma, Vermont, Virginia, and Wyoming. The reforms vary by state, but generally focus on reducing administrative burdens, improving transparency, and speeding up the prior authorization approval process to minimize delays in patient care.

Some key aspects of these state reforms include:

  • Shorter response times for urgent and non-urgent prior authorization requests;
  • Increased transparency, requiring insurers to publish their PA requirements and processes online;
  • Extended validity of prior authorizations for chronic conditions or ongoing treatments to prevent repeated PA requests; and
  • Gold-card programs currently available in two states:
  1. Wyoming: Providers with a strong approval history can bypass prior authorizations for select services. Payers are required to respond within 72 hours for urgent requests and within five calendar days for non-urgent requests.
  2. Texas: The gold-card law allows providers with a 90% approval rate for prior authorization requests over a six-month period to completely bypass the prior authorization process for certain procedures.

When it comes to reforming prior authorization, much of the work happens behind the scenes. The American Medical Association (AMA) Advocacy Resource Center (ARC) plays a crucial role in improving prior authorization at the state level by advocating for reform. The ARC partners with state lawmakers and medical societies to promote legislation aimed at streamlining prior authorization processes within individual states. This includes pushing for laws that set clear timelines for approvals, reduce unnecessary delays, and create transparency in insurance practices.

The ARC provides state-specific resources, tools, and data to assist health care professionals in advocating for change and ensuring compliance with evolving regulations. Additionally, it works with state insurance commissioners and other stakeholders to standardize prior authorization requirements, helping to eliminate variations that create inefficiencies. By focusing on state-level reforms, the ARC ensures that patients receive timely care and that the regulatory environment supports a more efficient, patient-centered health care system.

The roles of state and federal legislators in health care are deeply intertwined, with federal lawmakers setting broad national policies and funding mechanisms, while state legislators tailor and implement these policies within their specific contexts. This balance allows for both consistency in national health care programs and flexibility to address local health care needs.

For further information, visit fixpriorauth.org.

 

Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on X by following @Neurosurgery and using the hashtags #PriorAuth and #FixPriorAuth.

 

Ann R. Stroink, MD, FAANS, FACS

AMA Council on Legislation

AMA Mobility Caucus AANS/CNS Neurosurgery Delegation

Adjunct Professor of Neurosurgery Illinois State University

February 18, 2026
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Washington Committee: 50 Years of Advocacy and Impact

By AANS Spotlight, CNS Spotlight, NeurosurgeryNo Comments

Fifty years ago, the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) recognized the growing impact of federal policy on medicine and took bold action: they established the AANS/CNS Washington Committee for Neurological Surgery. This formal presence in the nation’s capital has since served as the unified voice of neurosurgery in Congress and within federal agencies.

“Throughout its history, the Washington Committee has been critical to CNS’ mission of enhancing health and improving lives. We are grateful to our Washington Committee representatives for their tireless efforts to ensure healthcare policies are patient-centered and address the needs of both patients and neurosurgeons,” states Regina Shupak, CNS CEO. Since its inception in 1975, the Washington Committee has worked to advance neurosurgery, influence policy decisions, and advocate for patient access to high-quality neurosurgical care.

Over the decades, the Washington Committee broadened its focus to address the full range of federal policies impacting neurosurgical practice and patient care — from reimbursement and medical liability reform to quality reporting, research funding, and access to innovative technologies. This strategic expansion has ensured that neurosurgery remains at the table and it has also achieved meaningful policy victories.

To keep pace with a rapidly evolving policy landscape, the Washington Committee expanded its structure, establishing subcommittees led by neurosurgeon volunteers that focus on key areas such as coding and reimbursement, clinical guidelines, medical device regulation, public communications, and quality improvement. It also includes delegates to the American Medical Association to maintain influence in organized medicine. Supporting this work has grown from a single staff member to a team of five, complemented by experienced consultants and targeted coalitions that the Committee has established and supports to advance key advocacy priorities.

“The Washington Committee has been at the forefront of major health care policy issues for 50 years, successfully advocating for fair reimbursement, reducing regulatory burdens, and securing funding for critical neurosurgical research and training. Through its steadfast dedication and strategic advocacy, the AANS and the CNS have preserved access to life-saving neurosurgical care for patients while ensuring neurosurgeons can continue to innovate and lead in an evolving health care landscape,” states Katie O. Orrico, JD, AANS CEO.

“The Washington Committee’s accomplishments over the past five decades highlight the incredible dedication of our neurosurgeons — both in the operating room and in the halls of Congress — and it has been an honor to play a small role in helping advance sound health policy. As we look to the next 50 years, the work of the Washington Committee is more critical than ever to help neurosurgery navigate complex policy challenges and drive meaningful legislative and regulatory change to preserve the specialty for generations of neurosurgeons and patients to come,” Ms. Orrico added.

The Washington Committee remains committed to advancing policies that support neurosurgical excellence, scientific innovation, and equitable patient access. Its legacy of impact reflects the strength of neurosurgery’s collective voice — and its future depends on continued engagement from the neurosurgical community.

Editor’s Note: This article originally appeared in the Spring 2025 CNS Congress Quarterly. We hope you will share what you learn from our posts. We invite you to join the conversation on X by following @Neurosurgery, @AANSNeuro, and @CNS_Update.

January 6, 2026
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Prior Authorization’s Hidden Toll: How Bureaucratic Barriers Exhaust Healthcare Teams and Delay Patient Care

By Prior AuthorizationNo Comments

The mechanism of prior authorization necessitates that an insurance company grants approval for specific treatments before assuming financial responsibility. This includes surgery but also clinical tools such as imaging and medication. This bureaucratic impediment functions mostly as a deterrent, a labyrinthine cacophony of obfuscation. In the words of Sir Topham Hatt, it causes confusion and delay. The deleterious impact on patients is palpable, and the toll on medical professionals is equally corrosive.

Data from the American Medical Association (AMA) in 2023 noted that 94% of physicians reported that prior authorization delays care. Nearly 1 in 4 physicians report that the prior authorization process resulted in serious adverse event to their patient. This bureaucratic quagmire results in real harm to real patients.

Yet, beyond the well-documented patient harm lies an underappreciated consequence: the stress imposed upon our health care staff. No one dedicates their life to health care only to have to attempt the daily Sisyphean task of try to win the coveted prior authorization. The same AMA study noted that physicians and their staff spend 12 hours each week completing prior authorizations. On average, a practice completes 43 prior authorizations for each physician per week.

To be blunt, there are legitimate economic apparatus in the insurance market that warrant a prior authorization structure but the process has become corrupt. It’s a tangible manifestation of a system designed to interpose a wedge between physician and patient in a manner which is borderline insidious. I’ve written about prior authorization for about a decade; here, here, here, and here to name a few.

Rather than regurgitate the same arguments, I thought I would take the opportunity to ask our staff about their journey through the Byzantine web weaved by the forces of prior authorization.

They were more than happy to oblige. So what precisely did they have to say?

 

Haley N. Kirby, MSEd., ATC/L

Director of Operations for Neurosurgery

“Prior authorization has become an increasing threat to our ability to run an efficient practice. We can’t keep up. It’s pervasive, and it’s impacting my staff and our ability to treat patients. The other challenge we feel is that it’s hard to win the game if the rules keep changing in the opposition’s favor. We have difficulty planning an actual reliable OR schedule.”

 

Samantha Schmitt

Neurosurgery Practice Manager

“For 7 doctors, we utilize 3 full-time staff just to do prior authorizations for hospital procedures. Each authorization can take anywhere from 15 minutes to 3 hours. If not more, waiting on a response and getting to the correct area of authorization.”

 

Victoria Hyatt, PA-C

Spine Clinic Physician Assistant

“Prior authorization stops us from being able to take care of patients, and it’s very stressful. They always wait to the last minute, and it creates so much a tension. I feel it’s an intentional tactic so that we are forced to cancel the case. And when we can’t get approval, the patients are looking to us for answers.”

Chelsea Lukenbill, PA

Spine Physician Assistant

“It’s difficult to even set up the call to speak with a provider. It’s not uncommon to be transferred multiple times before you speak with the person who schedules the appointments. Then you have to schedule a time for them to call you, which may not be until days later. When you do finally have the scheduled phone call, the provider may not even be in the same specialty.”

 

Stephanie James

Neurosurgery Patient Navigator and Coordinator

“I see where cases get delayed and some patients surgery dates have to be pushed out further because of the prior authorization, and all I can say is that Prior authorization really stinks and it’s the patients who are ones paying the price. Some of the patients really need the surgeries but the authorizations are what stop them.”

 

Erin Roberts, RN

Spine Nurse Emeritus

Erin has probably had the most interaction in our prior authorization practice, and wrote about it here.

“My favorite subject… When I deal with denials and call insurance companies, I’m transferred a minimum of three times, and everyone tells me completely contradicting information- and then when I call again the next day to check the status of things- I am again told conflicting information. This is difficult in urgent patients who need surgery within 2-3 weeks. Turnaround time for case determinations varies widely with insurance companies and we are often at their whim of determining when patients can have approval for surgery.”

 

Personally, I think the quote from my patient in clinic sums it up the best.

Patient CK

Spine Patient

“What the insurance company did to me in delaying my surgery was criminal. I was suffering for months. It was horrible, absolutely horrible.”

Our patients and our clinical teams deserve better. Tell Congress to fix prior authorization. The Improving Seniors’ Timely Access to Care Act has been reintroduced in the House and Senate (S. 1816/H.R. 3514). Its goal is to streamline prior authorization for Medicare Advantage.

It’s a start in the right direction. I know Haley, Sam, Tori, Stephanie, Ashley, and Erin would really appreciate it.

Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on X by following @Neurosurgery and using the hashtags #FixPriorAuth and #PriorAuth.

 

Richard P. Menger, MD, MPA, FAANS
USA Spine Institute
Mobile, Ala.

January 5, 2026
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Prior Authorization: Best of Intentions Turned Barrier to Care?

By Prior AuthorizationNo Comments

Prior authorization (noun): the process by which an insurance company evaluates a recommended health care service including a prescription, test, or treatment, is medically necessary and covered by the insurance plan.

Initially prior authorization was valiantly born to try and reduce unnecessary testing and control health care spending. With concerns that physicians were ordering unnecessary tests, prescribing unindicated medications, or moving forward with unproven treatments, prior authorization was implemented. This process, purportedly using guidelines to determine appropriateness of care, requires pre-approval for prescribed testing and treatments. The irony is that it has likely curtailed appropriate testing and treatment, while simultaneously delaying appropriate care for our patients and contributing to increased health care costs in overhead spending. A survey by the American Medical Association found that 69% of physicians reported that prior authorization resulted in ineffective initial treatments, 68% reported prior authorization resulting in additional office visits, 42% stated this resulted in immediate care or emergency department visits, and 29% reported this process resulted in a hospitalization. The Council for Affordable Quality Healthcare reported an increase in $1.3 billion on administrative costs in one year specifically related to prior authorizations.

In the end, this costs our patients. It costs them access to necessary medications, indicated testing to help guide treatment, and delays or cancels necessary procedures and surgeries. Patients are denied covered care, leading them to either continue in suffering or pay out of pocket for health care which should be covered by their insurance plans. Equally bad, the bureaucracy of prior authorizations can lead to delays in diagnosis or delays in care — placing patients at risk for worsening disease processes and the need for more significant interventions.

Where did this go so wrong? How is this affecting our patients? And most importantly, what can we do about it?

In this upcoming series on the Neurosurgery Blog, we highlight the current state of prior authorization and the impact it has had on our ability to provide appropriate care to our patients. We also highlight what we, as a specialty and profession, are doing to improve this process for neurosurgeons, physicians, and, most importantly, our patients.

Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on X by following @Neurosurgery and using the hashtags #FixPriorAuth and #PriorAuth.

 

Krystal L. Tomei, MD, MPH, FAANS, FACS, FAAP
Rainbow Babies and Children’s Hospital
Cleveland, Ohio

November 25, 2025
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Cross Post: CNS Publishes New Guidelines on Care for Adults with Functioning Pituitary Adenomas

By Brain Tumor, Cross PostNo Comments

From time to time on the Neurosurgery Blog, you will see us cross-posting or linking to items from other places when we believe they hit the mark on an issue. We wanted to bring attention to a recent online-only supplement in Neurosurgery, “Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Functioning Pituitary Adenomas.” Neurosurgery is the official journal of the Congress of Neurological Surgeons, which provides multimedia, prompt publication of scientific articles on clinical or experimental surgery topics important for the brain, spine, and peripheral nerves, reviews, and other information of interest to readers across the world.

Published August 15, 2025, the supplement provides comprehensive, evidence-based guidelines on the care of adults with functioning pituitary adenomas (FPA). Tailored for neurosurgeons, endocrinologists, and other specialists, the guidelines mark a pivotal step in standardizing care, optimizing patient outcomes, and promoting multidisciplinary coordination.

The CNS and the American Association of Neurological Surgeons (AANS) have endorsed the guidelines. The initiative was led by Isabelle M. Germano, MD, MBA, Professor of Neurosurgery at the Icahn School of Medicine at Mount Sinai and Chair of the AANS/CNS Section on Tumors (2022–2024), along with D. Ryan Ormond, MD, PhD, Associate Professor of Neurosurgery at the University of Colorado School of Medicine. Together, they assembled and worked with a multidisciplinary team of 18 experts in neurosurgery, endocrinology, neuroradiology, and radiation oncology from across the country to develop these guidelines.

To access the full supplement, click here.

 

Artwork by Maria Margalit Bederson, MD, MS ©2025. Used with permission. All rights reserved.

August 26, 2025
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100 Years Young and Still Towering: Celebrating Dr. Don Dohn, Neurosurgery’s Living Legend

By Faces of Neurosurgery, Mentoring, Neurosurgery MonthNo Comments

There are neurosurgeons who make a mark — and then there’s Dr. Donald F. Dohn. On August 16, Don turns 100 years old, and we’re not just lighting candles — we’re celebrating a legacy that shaped the very foundation of modern neurosurgery. From his early days in Buffalo, New York, to the hallowed halls of the Cleveland Clinic, Don’s story is the stuff of legend. After earning his medical degree from the University of Buffalo, he trained under giants like Dr. Walter Hamby and Dr. W. James Gardner, Jr., becoming a force of nature in his own right. He didn’t just train neurosurgeons — he built neurosurgical training. Over 45 neurosurgeons and fellows passed through his tutelage as he helped formalize the educational structure of neurosurgical residency, moving it beyond the traditional apprenticeship model.

Read More

August 8, 2025
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Celebrating 75 Years of NINDS: Dr. Christopher Getch’s Enduring Impact on Neurosurgery and Service

By CNS Spotlight, Faces of Neurosurgery, Medical ResearchNo Comments

Chris was born Dec 22, 1961, in Milton, MA. His family had a legacy of several generations attending the prominent Milton Academy, and Chris followed in those footsteps, as he was often proud to point out. He attended Princeton University, followed by medical school at Tufts. His career was shaped by his neurosurgical training at Thomas Jefferson University, where he developed a passion for cerebrovascular surgery under the guidance of Dr. William Buchheit. He then pursued a fellowship in Pittsburgh under Drs. Peter Janetta, Dade Lundsford, and Douglas Kondziolka, where he honed his microvascular and radiosurgery skills.

Chris joined the faculty at Northwestern in 1996 after finishing training. It was a unique time in the department, as Dr. Hunt Batjer had started as Chair only the year before, and the faculty was being completely revamped.  Chris came to Dr. Batjers’ attention when, at an AANS/CNS Joint Officers meeting at the O’Hare Hilton, Dr. Buchheit and Dr. Ed Laws approached him and said, “We have the perfect faculty member for your new department; his name is Chris Getch”.  Hunt called his cell immediately and had a 30-minute discussion, followed by an invitation for an interview in Chicago.  His recruitment provided Chris with an opportunity to play a significant role in shaping the program’s future. Chris rose to the rank of Professor of Neurosurgery at Northwestern and trained a generation of neurosurgeons during his time there. He was a master surgeon who delighted in performing rigorous cerebrovascular procedures, especially microvascular decompressions for trigeminal neuralgia and hemifacial spasm. He would show off the anatomy of a procedure to the entire operating room, explaining everything on the screen while mentoring the residents. He was fascinated by facial pain and even barged into one of our offices one afternoon, demanding to see a Schaltenbrand-Wahren stereotactic atlas to better understand the procedure that a patient he had seen in the clinic that day had undergone elsewhere.

We were his trainees (BB) and junior partners (BB and JR). Chris always made time to go over case plans with us and to join us in the operating room during the early years of our practice to provide support and technical assistance with challenging anatomy. His steady presence gave us the confidence to stretch our skills and become better surgeons. His rounds were legendary as he was able to spot subtle clinical signs and symptoms that remained invisible to the rest of the team. No one could sense the onset of vasospasm sooner than Chris. Neuroradiologists were always on alert for his phone calls to notify them of subtle findings they may have missed, but Chris did not. He was intense but amiable in how he challenged everyone around him. His laugh could be heard down the hall as he engaged students, colleagues, nurses, and partners in a jovial and collegial way that was his signature. He expected excellence but was the first to admit his failures and defeats. He would let you know when you fell short, but also acknowledged when you performed well. He suffered deeply with complications and always put his patients first. He was in love with the aesthetic of clean microsurgery and insisted on high standards of surgical finesse with his trainees.  He was a superior partner who would come in on off hours and weekends to handle cerebrovascular cases that came into the hospital while someone not specializing in those patients was on call. In fact, the last case he performed was an aneurysm clipping on a Sunday morning in one of these situations. He published over 75 peer-reviewed papers and numerous book chapters related to the surgical treatment of cerebrovascular disease and facial pain.

Importantly, Chris had significant influence outside the operating room. He served on the Board of Think First and worked with the Brain Aneurysm Foundation. He was the President of the Illinois State Neurosurgical Society and a driving presence during the state’s medical malpractice crisis. He was elected to the Executive Council of the AANS/CNS Joint Section on Cerebrovascular Surgery and the Executive Committee of the Society of Neurological Surgeons. He served as a guest examiner for the ABNS oral exams.

He served the Congress of Neurological Surgeons (CNS) in numerous roles, including a 10-year term on the Executive Committee. He was Chair of the Host Committee for the 1997 Annual Meeting, Scientific Program Chair for the 2005 Annual Meeting, and Chairperson of the 2006 Annual Meeting. He served as Vice President of the CNS from 2009 to 2010 and as President of the CNS from 2010 to 2011.

Chris had four sons from his two marriages. He delighted in adding the suffix “bear” to their names whenever he spoke of them (no matter how old they were!). He loved watching them play sports and doing outdoor activities with them. A special place for Chris was his family’s camp in the Canadian wilderness. Whenever possible, they made a family pilgrimage to that site. He was an avid model railroad enthusiast who maintained a large setup in his basement to which he was always adding new and often rare train cars or scenery.

Tributes to Chris’ influence have abounded in the wake of his untimely passing in January 2012. In 2015, the CNS and the National Institute of Neurological Disorders and Stroke (NINDS) established the NINDS/CNS K12 Getch Scholar Award. This 2-year award, funded by the CNS Foundation and NINDS, supports young surgeons early in their practice who wish to develop into productive surgeon-scientists. The Northwestern University Department of Neurosurgery has endowed the Getch Lecture, given each year during resident graduation. In recognition of the value Chris placed on multidisciplinary collaboration, the Department annually awards the Christopher Getch Clinical Excellence Award to a non-neurosurgeon or group that significantly contributes to the Department’s mission. In addition, the Brain Aneurysm Foundation Medical Advisory Board and Board of Directors established The Christopher C. Getch, MD, Chair of Research. The Illinois State Neurosurgical Society annually gives a Christopher Getch Distinguished Service Award to a member neurosurgeon along with the ingredients for Chris’s favorite drink, the Dark and Stormy.

Authors:

Joshua Rosenow, MD
Northwestern University Feinberg School of Medicine
Chicago, IL

 

Bernard Bendok, MD
Mayo Clinic
Phoenix, AZ

 

Hunt Batjer, MD
University of Texas at Tyler School of Medicine
Tyler, TX

June 26, 2025
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