John Lam, MD, outlines key policy priorities to streamline prior authorization in urology

Prior authorization continues to be one of the most significant administrative challenges facing urologists and other specialists, often delaying care and adding strain to already overburdened clinical practices. Despite ongoing efforts to reform the system, many physicians continue to face delays, inconsistent requirements, and significant administrative strain as they work to secure approval for imaging, procedures, and medications that are often essential to timely patient care. These challenges contribute not only to practice inefficiencies, but also to physician burnout, which is an issue that continues to grow across medical specialties.

In urology specifically, prior authorization barriers can lead to delays in diagnosis or treatment for conditions such as kidney stones, urinary tract infections, and urologic cancers, which often require prompt evaluation and intervention. With these delays, patients may experience worsening symptoms or end up in emergency departments for issues that could have been managed effectively in an outpatient setting. At the same time, physicians and other staff are spending substantial amounts of time navigating forms, appeals, and payer-specific requirements that can vary widely.

To better understand the policy landscape and the potential reforms that could help streamline this process, Urology Times® spoke with John Lam, MD, state advocacy network chair for the American Association of Clinical Urology (AACU). In the following discussion, Lam outlines the legislative efforts underway, the impact of prior authorization on patient care, and the role organized medicine can play in pushing for meaningful change.

Urology Times: Prior authorization remains a major administrative burden for physicians. What policy changes would you like to see implemented to create more uniformity in this process?

Lam: Prior authorization has been a hot topic in medicine over the last few years. It's a big contributor to the increase in administrative burden, affecting physicians’ practices and even physicians’ well-being in terms of burnout and having joy in work.

There are some bills that are currently out there that we're all closely following and supporting to create more uniformity in the process and reduce administrative strain. One of the things that has been proposed is having uniform forms amongst payers to decrease time and effort needed to complete these forms. This form should cover all the common elements for a prior authorization review and be structured in a way that's not cumbersome or burdensome. There should also be standardized criteria. We've been pushing for a national set of evidence-based standardized approval criteria for commonly prescribed treatments or procedures that would provide more clarity for physicians. [This would] reduce the number of unnecessary requests, knowing that there's some consistent decision-making amongst all insurers.

Another thing that's helpful is real-time prior authorization decision-making and automated systems, which cut down on the wait time. For the procedures or medications that are routine, they should be automatically approved instead of having us jump through hoops just to get something approved. It's unfair for the patients and it's unfair for the doctors what some of these insurance companies are making us go through. With artificial intelligence, we can improve and expedite the prior authorization process by being able to automatically review requests [based on] standardized criteria.

There’s also been concern about transparency with the prior authorization process. There’s been a push to publish clear, up-to-date prior authorization guidelines so you're not left in the dark. This allows physicians to easily access the specific criteria that are needed for approval, reducing confusion and streamlining the process. It may also be nice to have public reporting on prior authorization data so physicians can know the rates of approval or denial or the turnaround times [for requests]. It would also be nice to have timely processing and appeals. [For instance, we could implement] laws or regulations [where we need to] have prior authorization decisions within a certain set time frame, so you're not waiting weeks to hear a result. [This could be, for example,] 48 to 72 hours for routine requests and maybe a less than a 24-hour time period for more urgent requests.

Integration with health IT systems [is another potential area for improvement]. This is a challenging problem because we all have our different electronic medical records, but if there's an ability to integrate more closely with our electronic health records, that would also provide a more streamlined [process]. [Physicians could then] electronically submit these requests as opposed to having somebody from your office write out the paperwork and fax it in or calling someone trying to get prior authorization approval. By having things done electronically, where you can fill out the form and push a button, that can also streamline the efficiency for prior authorization.

Some other thoughts in the future [could be] providing financial incentives for prior authorization processes, because it does take a lot of the time out of the office with all this burden. Our policy makers could create incentives for insurers to implement more prior authorization processes, or maybe some reimbursement could be provided for prior authorization-related administrative costs and burdens.

Urology Times: How does prior authorization affect patient access to timely urologic care, and what are some of the consequences for outcomes?

Lam: Our patients do suffer when they're waiting for approval, so one of the things that we could improve upon is the wait times with prior authorization. You can have delays in diagnoses as well as treatment. Think about somebody who's suffering from a kidney stone and is in pain, but they're waiting for their approval for either getting a CT scan or surgery. Those are unnecessary things that could even lead to life-threatening complications. One of the other things that can happen is if the patient is suffering, where do they go? They end up going to the emergency room, and that backs up emergency room care, and that contributes to the rising cost of health care in some sense. When you're dealing with things like cancer and you're waiting for imaging studies, the patients are [struggling] even mentally.

As I mentioned, prior authorization can really affect quality of life, whether it be urinary tract infections or kidney stones that are causing a lot of pain and disruption to a patient's daily life. Just the associated anxiety and stress of waiting for the prior authorization approval process can affect a patient's mental health. Again, if you're getting delays in medications or treatments, [that] can increase the risk of complications. Often, say for instance, we're treating something like bladder cancer, there's a bit of coordination between chemotherapy and when to schedule surgery. If we're not able to do that in a timely fashion, sometimes that can impact cancer outcomes. Waiting for prior authorization is a big problem that really affects patient lives.

Urology Times: What role can organized medicine and specialty societies play in advancing reforms around prior authorization?

Lam: Some of the things that we can do as organized medicine as well as our specialty societies is advocacy, education, and collaboration with different stakeholders. We can leverage our collective strength and push for reforms to streamline the process and hopefully improve patient access to care and reduce unnecessary delays. Engaging in legislative advocacy, that's something that I do and lead as the state advocacy network chair. I try to engage other urologists in different states if there's certain legislative processes or bills that are introduced that can improve prior authorization. We have a lot of resources, such as the American Medical Association, the American Urological Association, and the American Association for Clinical Urologists. We have staff members who can help us lobby and even screen through bills, but the power for the physician is being able to stand up and provide testimony amongst the legislators. Legislators see value in physicians telling their story.

[It’s also important] to collaborate with payers to streamline the prior authorization process and set up a dialogue with insurers to find out what we can do. We’re trying to work with them to save money overall. [We can also focus on] providing education to our stakeholders as well as other physicians in terms of best practices for navigating the prior authorization process. [Some ways to] make things easy could be to distribute templates and model letters for submitting prior authorization requests, just to decrease the administrative burden. Even publishing research on the need for prior authorization reform [is helpful]. If we can show how this increases the cost of health care and hurts our patients, that will be very valuable. It’s also nice to also have the public on your side. If you can build public awareness, that provides a stronger coalition for our legislators to provide reform so we’re able to help take care of our patients better.