Prior authorization is jeopardizing access to critical care

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OPINION – Imagine your life changing in an instant. Whether a car accident causes an acute trauma, a stroke or an athletic injury impairs your ability to move, or a chronic condition regularly gives you pain, your ability to walk, move, or perform simple tasks like all become challenges. Now, imagine you seek help from a physical therapist, but your insurance company or managed care plan denies you every step of the way using the term “prior authorization.”

Rigid, algorithm-based prior authorization reviews undermine clinical judgment, prolong pain, slow recovery, and drive-up health care costs. These types of delays in care aren’t just frustrating, they’re dangerous.

Physical therapists help individuals rebuild their strength, mobility, and confidence. It’s more than physical recovery, it’s emotional healing for post-surgical patients, individuals living with Parkinson’s disease and other movement disorders, children with cerebral palsy or other developmental conditions, and those recovering from work and athletic injuries. Progress often begins with small movements and builds toward life-changing breakthroughs. Every patient’s journey is unique and decisions about their care must remain personalized.

Yet today, insurance and managed care companies are placing arbitrary limits on patients’ access to care. Some claim they offer an unlimited amount of physical therapy visits, but they don’t in practice, with many patients forced to pay for their treatments out-of-pocket, ration their sessions, wait while “authorization” is given, or go without treatment entirely.

Earlier this year, UnitedHealthcare implemented a new policy for Medicare Advantage plans requiring prior authorization after just six visits for physical therapy, occupational therapy, and speech therapy regardless of the patient’s condition or a physician’s recommendation. For a survivor learning to walk again after a stroke, six visits are rarely enough to make progress.

Fortunately, Assembly Member Mark González (D-Los Angeles) understood the need to resolve the egregious use of prior authorization. His bill, AB 574, will ensure patients can access up to twelve visits of physical therapy before prior authorization is implemented for new or recurring conditions. Benchmark data shows that twelve visits are sufficient for 90% of patients, both surgical and non-surgical, which means patients could be treated efficiently under his bill.

The bill also improves transparency by requiring providers to verify insurance coverage and disclose potential out-of-pocket costs upfront. So, instead of providers wasting valuable time on paperwork, they can spend their time where it is most vital – on their patients.

While health insurers and plans argue AB 574 would create “unfettered access” to physical therapy and drive-up costs to the health care system, the opposite is true. Studies consistently show that early, uninterrupted access to physical therapy can cut health care costs by as much as 75% by preventing complications, emergency visits, reliance upon painkillers, and costly surgeries. Prior authorization is not just a paperwork burden, but a direct threat to patient health.

AB 574 builds on a growing national trend toward patient-centered care, aligning California with states that have recognized the dangers of unnecessary insurance delays. Maine and Indiana already exempt the first twelve physical therapy visits from prior authorization, and others including Oregon, Georgia, and Michigan have passed similar reforms.

As AB 574 moves through the Legislature, I urge lawmakers, Governor Newsom, and every advocate for patient access to stand with us. Together, we can expand access, increase transparency, and remove unnecessary barriers to care so patients can take their next steps toward healing.

Movement is essential to human beings, and physical therapy isn’t a luxury – it’s a lifeline that helps people of all ages, backgrounds, and conditions regain control of their lives.

Rick Katz, PT, DPT, MA, is President of the California Physical Therapy Association.