APTA, Provider and Patient Groups Push Major Reforms to Prior Authorization

APTA has joined a broad coalition of national provider and patient organizations to release a new policy framework aimed at tackling one of the most persistent barriers to timely therapy: the misuse of prior authorization and utilization review.

The new framework, titled "Care Delayed Is Care Denied: A Therapy Consensus to Reform Prior Authorization," was developed by APTA, APTA Private Practice, and the American Occupational Therapy Association, with support from rehabilitation and patient advocacy groups across the country. It proposes a set of reforms intended to guide policymakers, payers, and utilization management organizations toward fair, evidence-based processes that do not impede medically necessary care or pull physical therapists away from patients.

APTA continues to strongly oppose the use of prior authorization and is actively advocating for federal and state policy solutions to end its misuse.

"Prior authorization requirements too often interfere with care that clinicians have already determined is medically necessary," said APTA President Kyle Covington, PT, DPT, PhD. "When patients are forced to wait for therapy, outcomes can suffer. Care delayed is care denied, and prior authorization practices must reflect that reality."

APTA Private Practice President Mike Horsfield, PT, MBA, said patients deserve timely, convenient access to care that is proven to improve outcomes and reduce overall health care costs. "It's time to eliminate arbitrary prior authorization barriers that delay treatment and stand between patients and the care they need."

The new framework is part of the ongoing work of the State Payer Advocacy Resource Consortium, or SPARC, to develop tools and resources that help APTA components and members advocate on payment issues.

What the Framework Calls For

The consensus outlines specific reforms that, if adopted, would put an end to some of the most problematic practices surrounding the use of prior authorization:

• End of utilization thresholds. Coverage determinations should be grounded in evidence and the standards of care rather than in utilization thresholds alone.
• Protections for continuity of care. Approved plans of care shouldn't be disrupted by changes to utilization review rules or by reviewers' discretion mid-course.
• Deadline for review of appeals. Appeals must be reviewed by clinicians licensed in the same specialty as the treating provider within 72 hours.
• True peer-to-peer reviews. Any required peer review should be conducted by a licensed clinician in the same profession as the provider of record.
• Standardized, interoperable systems. Plans should use consistent forms, data elements, and electronic workflows to cut duplicative submissions and speed determinations.
• Clear, evidence-based denial rationales. When services are denied or reduced, payers must provide specific, clinical explanations to guide next steps or appeals.
• Timely compensation for utilization review activities. Clinician time spent complying with utilization reviews should be recognized and compensated.
• Accountability via public reporting. Plans should report key metrics (e.g., denial rates, turnaround times) so providers and patients can see performance and equity impacts.

Bottom line: These guardrails are a first step to minimizing administrative burden and reducing delays that keep patients from starting or continuing medically necessary therapy, ultimately letting therapy providers spend more time with their patients instead of doing paperwork or trying to cut through red tape.

Explore the details: Review APTA's press release and the coalition's policy framework principles to see the full set of proposed principles.

Broad, Unified Support

The framework is also endorsed by organizations representing clinicians, rehabilitation providers, and patients, including ADVION, Alliance for Physical Therapy Quality and Innovation, American Association on Health and Disability, American Music Therapy Association, American Spinal Injury Association, Association of Academic Physiatrists, Center for Medicare Advocacy, Lakeshore Foundation, National Association of Rehabilitation Providers and Agencies, National Association of Social Workers, National Athletic Trainers' Association, and Rehabilitation Engineering and Assistive Technology Society of North America, among others.

What's Next and How APTA Members Can Engage

APTA and its coalition partners will continue urging policymakers, payers, and utilization management organizations to adopt the framework and modernize prior authorization for therapy services. Members can expect updates as these efforts advance and as opportunities arise to elevate the profession's voice.

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