Background
Medicare Advantage plans routinely use prior authorization to delay patient access to medically necessary care, creating substantial administrative burdens for specialty physicians and contributing to physician burnout. The HHS Office of Inspector General found that Medicare Advantage plans inappropriately deny medically necessary care that meets traditional Medicare coverage requirements and is supported by patient medical records. These delays harm patients and increase healthcare costs by leading to more visits to the doctor or emergency department, forcing many physicians to retire early or leave medicine entirely.
Legislation
ASE supports bipartisan legislation to reform prior authorization:
- Improving Seniors' Timely Access to Care Act (S 1816/HR 3514) - would streamline and standardize Medicare Advantage prior authorization
- Reducing Medically Unnecessary Delays in Care Act (HR 2433)- would require board-certified physicians in the same specialty to make prior authorization decisions
These reforms would ensure medical decisions are made between patients and their doctors without insurer interference, reducing administrative burdens on cardiovascular specialists while ensuring timely access to essential echocardiographic services for Medicare beneficiaries.
WISeR Model
Additionally, ASE opposes the Medicare Wasteful and Inappropriate Service Reduction (WISeR) Model, which would introduce prior authorization into traditional Medicare Fee-for-Service. This model risks replicating the same harmful delays and administrative burdens that plague Medicare Advantage. ASE supports Congressional efforts to halt implementation until meaningful stakeholder engagement occurs and proper safeguards are established to protect patient access to care.
Data on Prior Authorization
The AMA's 2025 prior authorization survey of 1,000 physicians paints a sobering picture: 95% report PA delays patient care, 92% say it harms clinical outcomes, and more than 1 in 4 say it has caused a serious adverse event for a patient. Add 40 PAs per physician each week and 94% citing worse burnout, and it's no surprise only 1 in 3 believe insurers' latest reform pledge will make a difference.
- Read the report here: AMA prior authorization physician survey.