Reforming prior authorization in Medicare Advantage plans | Bills and Laws

The Skinny

Lawmakers are pushing a measure to reform the prior authorization process in Medicare Advantage plans.

Sponsors

A bipartisan group of sponsors in the Senate and House are backing the legislation. Prime sponsors in the Senate include U.S. Sens. Roger Marshall, M.D. (R-Kan.), Kyrsten Sinema (I-Ariz.), John Thune (R-S.D.), and Sherrod Brown (D-Ohio). The House’s prime sponsors are U.S. Reps. Mike Kelly (R-Pa.), Suzan DelBene (D-Wash.), Larry Bucshon, M.D. (R-Ind.) and Ami Bera, M.D. (D-Calif.).

Dozens of other senators and House members are also listed as sponsors of the legislation.

Summary

Lawmakers say the legislation would streamline the prior authorization process in Medicare Advantage plans. Insurers, and Medicare Advantage, require hospitals and physicians to get authorization before moving ahead with treatment plans or surgical procedures.

The bill would require Medicare Advantage plans to move to an electronic prior authorization process by 2027. Plans would also have to respond more quickly to requests for approval. In addition, Medicare Advantage plans also have to report how often they are approving - and denying - authorization requests.

Analysis

Hospitals and physicians have denounced the prior authorization process. Clinicians say insurers are too often denying or delaying approval for treatment. More than 9 of 10 doctors say prior authorization delays are having a negative impact on patient care, according to an American Medical Association survey released last week. Roughly three-quarters of doctors say patients abandon treatment plans due to delays in getting approval.

Insurers say that prior authorization is a necessary mechanism to control healthcare costs and avoid procedures that aren’t medically necessary.

Hospitals and physicians say they are encountering more hassles in securing authorization from Medicare Advantage plans, which are utilized by more than 30 million Americans. More than 25% of claims to Medicare Advantage are subject to pre-approval from insurers, and 20% of hospital discharge requests to post-acute care facilities are initially denied, according to a Premier survey.

Lawmakers introduced a similar bill in the previous congressional session but couldn’t pass the measure before the session ended in 2022.

Marshall expresses optimism for swift passage.

“We will streamline prior authorization and help improve patient outcomes and access to quality care and life-saving medicine. With the improvements we’ve made there is no reason we should not quickly get this bill signed into law,” he said in a statement.

Supporters

Nearly 400 healthcare organizations and advocacy groups are backing the legislation, including the American Hospital Association, the American Medical Association, the American Nurses Association, and AARP.

“By removing unnecessary barriers that create delays in treatment, this meaningful bill will improve access to care for seniors and allow caregivers to spend more valuable time at the bedside with patients and less time on burdensome paperwork,” Stacey Hughes, executive vice president of the American Hospital Association, said in a statement.

Premier is also urging Congress to approve the legislation.

“Modernizing prior authorization for Medicare Advantage patients is vital to reducing the delayed care, harm and costs, which are the legacy of an antiquated process requiring faxes and phone calls in time-sensitive clinical situations,” said Soumi Saha, Premier’s senior vice president of government affairs.

Steven P. Furr, president of the American Academy of Family Physicians, says Congress needs to pass the bill “to ensure physicians can spend more time treating patients and practicing medicine.”

Outlook

The bill has unusually strong bipartisan support in a divided Congress, so that bodes well for passage. Hundreds of healthcare groups are backing the bill, which helps its chances.

Still, the bill boasted strong support two years ago before stalling. The House passed the bill in 2022, but it didn’t clear the Senate.

A key question: How much will Congress get done this year? Lawmakers recess in August, and most of Congress will be focusing on their re-election campaigns in September and October. Supporters may have to wait for the lame-duck session after the election to see if it passes.