Nearly 300 members of Congress urge CMS to reform prior authorization in Medicare Advantage

Nearly 300 members of Congress are urging President Biden’s administration to take some of the headaches out of prior authorization in Medicare Advantage programs.

U.S. Sen. Sherrod Brown, an Ohio Democrat, led fellow lawmakers in a joint letter asking the Centers for Medicare & Medicaid Services to approve reforms to streamline the prior authorization process.

A bipartisan group of  61 U.S. senators and 233 members of the U.S. House of Representatives signed onto the June 22 letter.

The CMS proposed a rule that would revamp prior authorization in Medicare Advantage plans. The rule would require some insurers to respond to prior authorization requests more quickly, and to make requests more transparent. Lawmakers also urged the CMS to approve a mechanism for “real-time” decisions on services and treatments that are routinely approved.

“We urge CMS to promptly finalize and implement these changes to increase transparency and improve the prior authorization process for patients, providers, and health plans,” the lawmakers wrote in the letter.

With prior authorization, doctors, physicians and health systems must get approval before moving ahead with many medications or treatment plans. Providers have said prior authorization has become increasingly difficult in the increasingly popular Medicare Advantage programs.

In a survey of more than 600 medical groups, 84% of respondents said prior authorization demands in Medicare Advantage plans have increased over the past 12 months, according to a report by the Medical Group Management Association.

Anders Gilberg, the MGMA’s senior vice president of government affairs, applauded the lawmakers for pushing for changes and said the Medicare Advantage program is “overdue” for reform.

“Prior authorization requirements are routinely identified by medical groups as the most challenging and burdensome obstacle to running their practices and delivering high-quality care,” Gilberg says. “Increasing prior authorization requirements are detrimental to both practices and the patients they treat. The onerous methods of completing these requests, coupled with the increasing volume, is unsustainable.”

Some of the lawmakers who signed the letter include U.S. Sens. Bob Casey Jr., D-Pa., Susan Collins, R-Maine; J.D. Vance, R-Ohio, and Elizabeth Warren, D-Mass.

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Medicare Advantage programs have surged in popularity in recent years, as seniors seek supplemental coverage to their traditional Medicare plans. More than 30 million Americans are now enrolled in Medicare Advantage plans, the CMS said in January. Insurers say the growth in Medicare Advantage plans reflects their value and appeal to consumers.

Payers point out that prior authorization is designed to reduce healthcare costs and to prevent patients from undergoing procedures that aren’t necessary.

However, doctors and health systems say that prior authorization hassles are hurting patient care. The American Medical Association says many patients give up on treatments due to delays in authorization, and doctors also cite the bureaucratic battles involved in authorization as a prime contributor to burnout.

The CMS proposal would call for some payers to move to fully electronic prior authorization by 2026. Supporters say that would speed up the process. Most prior authorizations aren’t fully electronic, analysts say.

Gilberg says the MGMA ultimately wants to see fewer authorization requests, but he adds, “an electronic program, if implemented appropriately, has the potential to alleviate administrative burden and allow practices to reinvest resources in patient care.”

Lawmakers, including members of both the Democratic and Republican parties, are taking more interest in Medicare Advantage plans.

The House of Representatives approved legislation to streamline the authorization process in Medicare Advantage plans last year, but the Senate didn’t pass the bill before the congressional session ended. The administration’s reform plans include many of the key provisions of the legislation.