Crawford Times

Jennifer Riley, executive director of Pennsylvania Patients Come First, said that prior authorization reform is gaining momentum in Washington due to widespread inefficiencies, particularly in Medicare Advantage plans. She made the statement in a March 11 op-ed.

"Prior authorization has become the number one administrative burden in health care," said Riley, Pennsylvania Executive Director. "Nearly one in four doctors say the practice of prior authorization has led to serious issues for patients. Over two weeks for his insurance company to approve the biopsy."

According to the U.S. Department of Health and Human Services, the push for prior authorization reform follows growing evidence that insurance-mandated approvals are delaying necessary treatments and adding administrative burdens. Medicare Advantage plans have faced scrutiny for initially denying claims that are later approved upon appeal. These denials create unnecessary barriers to care, forcing patients and providers to navigate lengthy appeals processes that delay essential treatments.

The Kaiser Family Foundation (KFF) reports that in Pennsylvania, 1.4 million people are enrolled in Medicare Advantage, with over a million subject to prior authorization requirements. This highlights the widespread impact of these policies. Physicians and healthcare providers in the state report that the administrative burden of obtaining these approvals diverts time away from direct patient care. Excessive prior authorization policies disproportionately affect vulnerable populations, such as seniors, by delaying access to necessary medical treatments.

Ropes & Gray reported that 75% of Medicare Advantage claims initially denied were later overturned upon appeal, raising concerns about unnecessary delays in patient care. Many of these denials occur despite patients meeting Medicare coverage requirements, indicating that prior authorization is being used as a bureaucratic hurdle rather than a legitimate cost-control measure. These delays have been linked to serious patient outcomes, including worsened conditions and life-threatening complications due to postponed medical interventions.

According to the Patients Come First website, Riley is a lifelong Pennsylvanian with over 20 years of experience in advocacy, public affairs, and strategic leadership. She has been recognized as one of Pennsylvania's most influential women for her contributions to business, public service, media, and nonprofits.