By Dr. Patricia Ares-Romero

Physicians are a cornerstone of healthcare delivery. Yet, despite their critical role, administrative burdens continue to erode time better spent on patient care. Among these burdens, the processes of prior authorization and retroactive claim denials present significant barriers, jeopardizing patient outcomes and physician practices alike. The Dade County Medical Association (DCMA) unequivocally supports the Florida Medical Association (FMA) in calling on the Florida Legislature to take decisive action in addressing these challenges.

A Growing Crisis

Prior authorization—initially designed to control costs and ensure appropriate care—has evolved into a cumbersome process fraught with delays. According to the American Medical Association, over 90% of physicians report care delays caused by prior authorization, with more than one in four physicians noting that these delays have led to adverse health events for patients.

Similarly, retroactive denials present a growing concern. When insurers authorize procedures or treatments but subsequently deny claims post-service, physicians face financial uncertainty, and patients are often left bearing the burden. These policies undermine trust in the payer-provider relationship and disrupt continuity of care.

A Legislative Imperative

For the dental profession, recent legislative amendments to Florida Statutes 627.6131 and 641.315 seek to curb these practices. For instance, the updated statutes prohibit health insurers and HMOs from mandating credit card payments as the sole reimbursement method. Furthermore, they establish the requirement for written physician consent for electronic fund transfers, ensuring transparency and consent for associated fees. These changes promote fair practices and operational transparency.

Significantly, the amended laws address retroactive denials. Under these regulations, insurers may only deny previously authorized claims under narrowly defined circumstances, such as benefit limitations being reached after authorization or fraudulent information in the claim. These changes establish necessary guardrails that protect providers from unjust financial penalties while safeguarding patient access to timely care.

The protections aforementioned were provided to Doctors in Dental Surgery (DDS) and Doctors of Medicine in Dentistry (DMD) and not to physicians at large, who should equally have the same protections.

The DCMA’s Commitment

The DCMA stands with the FMA in advocating for additional reforms to strengthen these measures. Physicians should not face unwarranted administrative hurdles to delivering patient care. The DCMA urges the Florida Legislature to:

• Apply the same protections granted to DDS and DMDs to physicians.
• Streamline prior authorization processes with mandatory electronic submissions and a standardized review timeline.
• Implement penalties for insurers failing to comply with these timelines.
• Mandate disclosure of all prior authorization requirements at the plan’s inception.
• Expand protections against retroactive denials, particularly for urgent or lifesaving procedures.

Looking Ahead

The path forward requires unwavering resolve from the medical community, policymakers, and patient advocates. As the voice for physicians in South Florida, the DCMA remains committed to reducing administrative obstacles to patient care. By championing these critical issues, the DCMA affirms its dedication to advocating for policies that protect the physician-patient relationship.

We encourage all stakeholders—healthcare providers, patients, and policymakers—to join us in demanding meaningful reforms. Together, we can shape a healthcare system where the focus remains where it belongs: on delivering quality care.

Dr. Patricia Ares-Romero is President of the Dade County Medical Association.