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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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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: ‘No other industry would tolerate this’: The problem with prior authorization in spine surgery

By Cross Post, Prior Authorization, Spine CareNo Comments

From time to time on Neurosurgery Blog, you will see us cross-posting to items from other places that we believe will interest our readers. Today’s post originally appeared in Becker’s Spine Review on Sept. 25. Neurosurgeons Anthony M. DiGiorgio, DO, MHA, FAANS; Praveen V. Mummaneni, MD, FAANS and Luis M. Tumialán, MD, FAANS discuss prior authorization and the significant problems physicians face when it comes to receiving fair payments for services offered.

Denial of payment after prior authorization has become a grim reality in American health care. Insurance companies authorize procedures, and surgeons perform them as approved. Then, the insurance company denies payment. The authors state, “No other industry would tolerate this system. Yet, in healthcare, physicians, bound by their oaths to care for patients, endure a system that withholds payment.”

Ultimately, patients bear the brunt of this charade. The authors conclude the article by stating that patients deserve insurance companies that fulfill their contractual obligations.

Click here to read the full article.

We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #FixPriorAuth.

October 6, 2023
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Cross-Post: When Insurance Fails

By Cross Post, Health Reform, Prior AuthorizationNo Comments

From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places that may interest our readers. Today’s post originally appeared in The Lincoln Journal Star, titled “When Insurance Fails.” In the op-ed, neurosurgeon Jeremy Hosein, MD, discusses the misuse of prior authorization, which delays care, prolongs suffering and adds significant administrative costs to health care.

Dr. Hosein relays a story of a 47-year-old female with nagging pain in her hip who was sent by her primary doctor to physical therapy and given pain medicine. When the pain persisted and caused difficulty walking, she was referred to an orthopedic surgeon who ordered an MRI. The insurance company denied the MRI, stating that the scan was not medically necessary and that she had not yet completed physical therapy. Her orthopaedic surgeon appealed the denial, and the MRI was eventually performed nearly six weeks later. Her cancer doctors said she could have avoided surgery had the tumor been discovered only weeks earlier.

According to Dr. Hosein, prior authorization is increasingly being used to deny or delay basic medical care such as blood tests, imaging and other medically necessary procedures. A 2023 Kaiser Family Foundation analysis found that 82% of appeals in Medicare Advantage resulted in overturned denials. Fortunately, some hope may be on the horizon, states Dr. Hosein. The Centers for Medicare & Medicaid Services issued rules to reduce the burden of prior authorization with an automated electronic process and to add transparency to the process.

Click here to read the op-ed and here to read more about CMS’ proposed rules.

Editor’s Note: Organized neurosurgery aims to protect patients’ timely access to care by streamlining the prior authorization process. Patients experience significant barriers to medically necessary care due to prior authorization requirements for items and services that are eventually routinely approved. In the 2023 Legislative & Regulatory Agenda, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons outline health policy action items the neurosurgical societies plan to advance with Congress and the Biden Administration.

We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #FixPriorAuth.

May 25, 2023
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Cross-Post: Ending the Health Insurance Monopoly Will Make Life Healthier for Alabamians

By Access to Care, Cross Post, Health ReformNo Comments

From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places that may interest our readers. Today’s post originally appeared on 1819 News on April 21, titled “Ending the Health Insurance Monopoly Will Make Life Healthier for Alabamians.” In the op-ed, Richard P. Menger, MD, MPA, assistant professor of neurosurgery and political science at the University of South Alabama in Mobile, Ala., discusses why broadening health insurance coverage options in Alabama will improve the state’s health care system.

Alabama is tied with Alaska as the least competitive insurance market in the nation, limiting patient options, hurting hospitals and physicians and feeding the insurance industry. Lack of competition also impacts prior authorization, a system where insurance companies must approve certain surgeries before they agree to pay for them, despite the physician and patient deciding upon a personalized treatment plan. Dr. Menger states that this is an intentional delay tactic, and the cumbersome apparatus frustrates families, hurts patients and burns out physicians.

Dr. Menger argues that the arc of reform needs to bend towards the injection of competition between and within state lines — With that will come better products, lower prices, higher quality and more innovation.

Click here to read the full op-ed by Dr. Menger.

Editor’s Note: Organized neurosurgery aims to improve competition in the health care system by broadening health insurance coverage options, increasing scrutiny of hospital and other health care consolidation, removing restrictions on physician ownership of hospitals and other ancillary services and establishing network adequacy standards.

We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery.

May 9, 2023
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Cross-Post: Insurance Companies Use Stalling Tactics to Save Themselves Money

By Access to Care, Burnout, Prior AuthorizationNo Comments

From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places that we believe will be of interest to our readers. Today’s post originally appeared in The American Spectator on Jan. 3. In the op-ed, neurosurgeon Richard Menger, MD, MPA, FAANS and nurses Jessica Murfee, RN, BSN and Erin Roberts, RN, BSN, discuss health care provider burnout from the cumbersome prior authorization process required by insurance companies to perform surgery agreed upon by patient and surgeon.

The time-consuming prior authorization process disregards the patient-physician relationship. It also causes burnout for health care workers, and “Most of the time, it’s an administrative clarification issue, but calling into the insurance abyss is like dialing into a time warp.”

See 2021 AMA prior authorization physician survey

A survey from the American Medical Association noted that, on average, offices spend 13 hours per week on prior authorizations. The article states, “If a higher-level evaluation is needed, either myself or my physician assistant or nurse practitioner will have to get on the line and debate the merits of a neurosurgery with some other type of health representative who is acting on behalf of the insurance company.”

The piece concludes with the authors asking Congress to take action and pass legislation to streamline prior authorization in Medicare Advantage. The Improving Seniors Timely Access to Care Act would require enhanced transparency and streamline authorization in the Medicare Advantage program.

Click here to read the full article.

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

January 18, 2023
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Cross-Post: Prior Authorization Is Hurting Our Patients

By Cross Post, Prior AuthorizationNo Comments

From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places that we believe will be of interest to our readers. Today’s post originally appeared in MedPage Today on June 25. In the op-ed, neurosurgeon and chair of the American Association of Neurological Surgeons/Congress of Neurological Surgeons Washington Committee John K. Ratliff, MD, FAANS, discusses how prior authorization is hurting patients and how bipartisan legislation in Congress can help address these problems in Medicare Advantage.

Dr. Ratliff points out that prior authorization, an administrative process requiring physicians to obtain pre-approval for medical treatments or tests before rendering this care to their patients, is becoming more common. Obtaining approval from insurers is burdensome and costly to physician practices. Without timely care, his patients often face permanent neurologic damage and sometimes death.

The Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018) would create an electronic prior authorization process and pave the way for immediate approvals for medical services that are routinely approved. This legislation would also improve transparency on the use of prior authorization, ensure that qualified medical personnel review prior authorization requests and protect beneficiaries from disruptions in care.

Click here to read the full article.

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

July 14, 2022
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Our 500th Blog Post: Amplifying Neurosurgery’s Voice

By HealthNo Comments

For the past decade, Neurosurgery Blog: More Than Brain Surgery has investigated and reported on how health care policy affects patients, physicians and medical practices. Posts have discussed the state of neurosurgical sub-specialties and promoted key health care policy and advocacy initiatives to ensure patients’ timely access to care, improve neurosurgical practice and foster continued advancement of neurological surgery.

Its health policy reporting efforts include multiple topic months and guest blog posts from key thought leaders and members of the neurosurgical community. To mark the 500th post, we combed through the Neurosurgery Blog archives to highlight our most popular blog posts and focus series that showcase the current state of neurological surgery.

The Neurosurgery Blog’s 10 top posts:

The Neurosurgery Blog’s top focus series:

  • WINS Series. The year 2020 marked the historic 30th anniversary of the founding of Women in Neurosurgery (WINS), bringing with it an exciting time for the WINS community and neurosurgery. To celebrate the 30th anniversary of WINS, Neurosurgery Blog published a series of articles highlighting the section’s goals — to educate, inspire and encourage women neurosurgeons to realize their professional and personal goals.
  • COVID-19 Series. The COVID-19 pandemic has significantly impacted neurosurgical practices across the country. To highlight the effects of the pandemic on neurosurgery, Neurosurgery Blog published a series of articles on the impact of COVID-19.
  • Spine Care Series. The Neurosurgery Blog published a series of articles on the spine to shed light on spine facts, innovation and the role of spine interventions. Today, spine-related disability has been called an epidemic. Misinformation regarding spine care in the U.S. is a significant hindrance to understanding the critical issues surrounding the care of patients with spinal conditions.
  • Military Faces of Neurosurgery Series. To pay tribute to the contributions of the many military neurosurgeons who have made significant contributions and sacrifices — whether on the battlefield, in the operating room or research lab — the Neurosurgery Blog published a series on Military Faces of Neurosurgery. Throughout history, neurosurgeons have served our country with distinction and grace. Read how former AANS president Roberto C. Heros, MD, FAANS(L), volunteered for the ill-fated Bay of Pigs invasion. Remember the horrors of the Vietnam War, as seen through the eyes of Patrick J. Kelly, MD, FAANS(L), while he was stationed in Da Nang during the bloodiest year of that conflict.
  • Physician Burnout Series. To explore and highlight the rising prevalence of burnout among clinicians in recent years, the Neurosurgery Blog published articles bringing physician wellness to the forefront of the profession and offering strategies to reduce physician burnout.
  • Faces of Neurosurgery Series. The Neurosurgery Blog published a Faces of Neurosurgery interview video series. Conducted by Kurt A. Yaeger, MD, a member of the AANS/CNS Communications and Public Relations Committee, these neurosurgery luminaries are asked about their early mentors, proudest achievements and advice for neurosurgical residents. Click here to watch the series.

Thanks for following Neurosurgery Blog, and stay tuned for great content in the coming decade!

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

July 12, 2022
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Cross-Post: Bipartisan Bill Would Improve Medicare Patients’ Access to Care

By Cross Post, Health Reform, Prior Authorization, Regulatory ReliefNo Comments

From time to time on 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. Today’s post originally appeared in The American Spectator on July 21, 2021. In the op-ed, Richard Menger, MD, MPA, assistant professor of neurosurgery and political science at the University of South Alabama in Mobile, Ala. discusses how H.R. 3173, the Improving Seniors’ Timely Access to Care Act, could bring transparency to the process of prior authorization in Medicare Advantage (MA) plans.

Prior authorization is a tool insurance companies use to limit the services they provide for their customers. If passed, this legislation would reduce prior authorization hassles and help curb unnecessary delays for patients. “It’s quite rare for a piece of legislation to have the direct ability to truly impact the lives of so many of my patients. It’s even rarer for that legislation to have bipartisan support,” according to Dr. Menger.

To bring needed transparency and oversight to the MA program, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) are urging Congress to adopt H.R. 3173, the Improving Seniors’ Timely Access to Care Act. Please contact Congress and ask your Representative to co-sponsor H.R. 3173.

Click here to go to neurosurgery’s Advocacy Action Center to send an email to your Representative asking them to co-sponsor the Improving Seniors’ Timely Access to Care Act. A sample message, which can be personalized, is provided.

Click here to read the full article in The American Spectator.

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

July 26, 2021
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