“Mind-Numbing” Mental Health Prior Authorization Process Discussed at Senate Hearing

(Washington, D.C., November 30, 2022) – U.S. Senator Roger Marshall, M.D. today at a Senate HELP Subcommittee hearing discussed the mental health crisis currently wreaking havoc across the nation and the issues patients and health care providers face when it comes to seeking care through the outdated prior authorization process. Senator Marshall brought up his legislation, the Improving Seniors’ Timely Access to Care Act (S. 3018 / H.R. 3173), which streamlines prior authorization making it easier for patients and health care providers to get the care they need in a timely manner. During the hearing Senator Marshall said in part,

“Prior authorization – access to care – is the number one physician and administrative concern in America. As an OBGYN, I saw the issue delay care for infertility patients, for high risk patients… In your clinical experience, when it comes to mental health issues, are you seeing any challenges in the prior authorization realm?”

Ashley Weiss, DO, MPH, Director of Medical Student Education in Psychiatry at Tulane University School of Medicine responded,

“It is mind-numbing… it will take weeks sometimes getting prior authorization for community based mental health services…”

Sharon Hoover, PhD, Professor of Psychiatry and Co-Director of the National Center for School Mental Health, University of Maryland School of Medicine responded,

“…The wait times for getting in to mental health care are mind-numbing, astronomical, and for families they can be really impossible to navigate.”

You may click HERE or on the image below to watch Senator Marshall discuss his prior authorization legislation at today’s hearing.

Background:

The Improving Seniors’ Timely Access to Care Act is bipartisan, bicameral legislation with support of 50 U.S. Senators, 327 U.S. Representatives, and endorsements from over 500 national and state organizations.

Prior authorization is a tool used by health plans to reduce spending from improper payments and unnecessary care by requiring physicians and other health care providers to get pre-approval for medical services. But it’s not without fault. The current system of unconfirmed faxes of a patient’s medical information or phone calls by clinicians takes precious time away from delivering quality and timely care. Prior authorization continues to be the #1 administrative burden identified by health care providers and nearly four out of five Medicare Advantage enrollees are subject to unnecessary delays. In recent years, the Office of the Inspector General at the U.S. Department of Health and Human Services (HHS) raised concerns after an audit revealed that Medicare Advantage plans ultimately approved 75% of requests that were originally denied. More recently, HHS OIG released a report finding that MA plans denied prior authorization and payment requests that Medicare coverage rules by requesting unnecessary documentation, making manual review efforts and system errors, and using MA plan clinical criteria that are not contained in Medicare coverage rules.

Health plans, health care providers, and patients agree that the prior authorization process must be improved to better serve patients and reduce unnecessary administrative burdens for clinicians. In fact, leading health care organizations released a consensus statement to address some of the most pressing concerns associated with prior authorization. Building on these principles, Senator Marshall’s bipartisan legislation would:

• establish an electronic prior authorization process that would streamline approvals and denials;
• create national standards for clinical documents that would reduce administrative burdens for health care providers and Medicare Advantage plans;
• create a process for real-time decisions for certain items and services that are routinely approved;
• increase transparency that would improve communication channels and utilization between Medicare Advantage plans, health care providers, and patients;
• ensure appropriate care by encouraging Medicare Advantage plans to adopt policies that adhere to evidence-based guidelines; and
• expand beneficiary protections that would ensure electronic prior authorization serves seniors first. 

U.S. Representatives Suzan DelBene (D-WA), Mike Kelly (R-PA), Ami Bera, M.D. (D-CA), and Larry Bucshon, M.D. (R-IN) lead the companion legislation. The companion legislation passed the House by voice vote in September. You can read Senator Marshall’s remarks following the passage here.

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