Prior Auth Legislation Moves One Step Closer to Becoming Law

(Washington, D.C., December 7, 2022) – The U.S. Centers for Medicare and Medicaid Services (CMS) released a proposed rule Tuesday evening that brings U.S. Senator Roger Marshall, M.D. (R-KS) and U.S. Representative Suzan DelBene’s (D-WA) legislation, the Improving Seniors’ Timely Access to Care Act, one step closer to becoming law. This bipartisan, bicameral legislation modernizes the way Medicare Advantage plans and health care providers use prior authorization, and in turn improves the timely access to care for America’s seniors. Since its introduction, over 500 organizations that represent patients, physicians, hospitals, and other key stakeholders in the health care industry have officially endorsed the legislation.

U.S. Senators Kyrsten Sinema (D-AZ), John Thune (R-SD), and Sherrod Brown (D-OH), as well as U.S. Representatives Ami Bera, M.D. (D-CA), Larry Bucshon, M.D. (R-IN), and Mike Kelly (R-PA) co-lead the legislation alongside Senator Marshall and Representative DelBene.

“The massive support for this legislation from Republicans and Democrats in both chambers of Congress, plus the more than 500 groups that have endorsed it, and now the CMS proposed rule, are all proof that this is truly a good faith effort to make health care better for America’s seniors,” said Senator Marshall. “Modernizing Medicare Advantage is the number one administrative hurdle for physicians and I can personally speak to these challenges as a physician myself and from my time managing Great Bend Regional Hospital. There’s a reason why the Improving Seniors’ Timely Access to Care Act is one of the most popular bills this Congress. I’m grateful for all the hard work that has gone into creating significant momentum for this bill – for it is this hard work that brings us closer to getting this over the finish line before the new Congress.”

“Seniors and their families should be focused on getting the care they need, not insurance paperwork. I welcome the proposed prior authorization rule from CMS as one more step towards bringing this process into the 21st century and improving the health of our seniors,” said Congresswoman Suzan DelBene (WA-01). “We cannot stop here. We need to get the bipartisan, bicameral Improving Seniors’ Timely Access to Care Act through the Senate and to President Biden’s desk before the end of the year. 

“Modernizing the prior authorization process allows Arizona seniors with Medicare Advantage plans to receive timely, quality health services while lowering the costs related to delayed care. Our bill also allows physicians and health care providers in Arizona to spend less time on burdensome red tape, and more time with their patients,” said Senator Sinema.

“I’m proud to continue working with my colleagues to advance policies that make health care delivery more efficient and patient-centered,” said Thune. “By implementing electronic prior authorization, providers are able to reduce delays and help seniors in South Dakota get quicker access to the treatment and care they need.”

“Older Americans shouldn’t be held up with unnecessary delays when seeking out medical treatment,”said Senator Brown. “We should be updating our systems so that they work better and faster for patients and providers. Requiring private insurance companies to streamline prior authorization processes electronically will allow providers to quickly access the information they need to treat and care for their patients in a timely manner.”

“As a doctor who has cared for our nation’s seniors, I know we should make it easier, not harder, for our seniors to get the care they need and deserve,” said Rep. Ami Bera, M.D., who previously served as Chief Medical Officer for Sacramento County. “That’s why I’m glad to see that our commonsense, bipartisan legislation to modernize Medicare Advantage is one step closer to becoming law. Administrative burdens for providers should never get in the way of providing the best possible care for patients.”

“Inefficiency within the prior authorization process in Medicare Advantage plans has created unnecessary paperwork, lag time, and hassle for doctors and can delay critical, sometimes life-saving procedures for patients in need. I am thrilled that the Centers for Medicare and Medicaid Services is working to address this through their proposed rule, taking key measures from the Improving Seniors’ Timely Access to Care Act to help fix and streamline the process. This is an important step toward putting patients over paperwork, allowing doctors to spend more time providing direct patient care and ensuring individuals receive the services they need in an appropriate timeframe,” said Dr. Bucshon.  

“When seniors go to the doctor, the focus should be on their health, not bureaucratic paperwork. That’s why CMS’ proposed rule yesterday was so important. It mirrors many of the most important elements of our bill, the Improving Seniors’ Timely Access to Care Act, and emphasizes the importance of an electronic prior authorizations system,” said Kelly. “It doesn’t address every problem in the prior authorization space, however, and there is still need for Congress to legislate to protect our seniors. I look forward to continuing to work with my colleagues to pass the Improving Seniors’ Timely Access to Care Act before the end of the year.”

Background:

In September, the House passed the Improving Seniors’ Timely Access to Care Act by voice vote. Since then, the Senate and House bill sponsors have been working with their colleagues and CMS to advance the legislation to the President’s desk. The bill has widespread bipartisan support in Congress and across the medical field.

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 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, the bipartisan legislation would:

• establish an electronic prior authorization process that would streamline approvals and denials;
• establish 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
• require beneficiary protections that would ensure the electronic prior authorization serves seniors first.

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