Why Prior Authorization Has Become a Breaking Point in Health Care

Episode Summary:

In this episode of Gosfield and Shay on Health Law, Alice Gosfield, a renowned healthcare attorney, joins host LeAnn Lyon to delve into the complexities of prior authorizations in the healthcare system. They explore the historical context and recent scrutiny of prior authorizations, revealing how these processes have become a significant burden for physicians and patients alike. Alice discusses the role of pharmacy benefit managers and the controversies surrounding their practices, as well as the challenges posed by predictive algorithms and artificial intelligence in decision-making. The episode also covers Medicare Advantage's role in the prior authorization debate and the implications of new CMS rules aimed at increasing transparency and efficiency. Listeners will gain insights into the ongoing reforms and the potential for meaningful change in the healthcare landscape.

Key Timestamps:

00:01 – Introduction

00:54 – The Rise of Prior Authorizations

01:09 – Burden on Physician Practices

02:22 – Role of Pharmacy Benefit Managers

03:36 – Industry's Response to Criticism

04:31 – Administrative Burden on Physicians

05:41 – Impact of Predictive Algorithms

06:42 – Medicare Advantage and Prior Authorization

08:11 – New CMS Rules and Their Impact

09:46 – State Regulations and Physician Rights

10:14 – Future of Prior Authorization Reforms

About the Show:

Gosfield and Shay on Health Law is a podcast dedicated to exploring the intricate world of healthcare law and policy. Hosted by healthcare attorney Alice Gosfield and LeAnn Lyon, the show offers insightful discussions on topics like Medicare, fraud and abuse, and healthcare regulations. With a focus on strategic clarity and practical guidance, the podcast aims to inform and empower physicians, healthcare professionals, and policymakers navigating the complex legal landscape of healthcare. Whether you're a seasoned professional or new to the field, this series provides valuable perspectives on the ever-evolving world of health law.