The House of Representatives on Wednesday passed bipartisan legislation that would streamline prior authorization requirements under Medicare Advantage (MA) plans
The Improving Seniors Timely Access to Care Act (H.R. 3173) now heads to the Senate, where it also has bipartisan support.
The bill aims to modernize the prior authorization process in MA by
- Establishing an electronic prior authorization process that would streamline approvals and denials
- Requiring the Department of Health & Human Services (HHS) to establish a process for “real-time decisions” for items and services that are routinely approved
- Improving transparency by requiring MA plans to report to the Centers for Medicare & Medicaid Services on the extent of their use of prior authorization and the rate of approvals or denials
- Encouraging plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians
- Establishing national standards for clinical documents that would reduce administrative burdens for health care providers and MA plans
- Requiring beneficiary protections that would ensure the electronic prior authorization serves seniors first
The legislation, which was passed by a voice vote, was sponsored by Reps. Suzan DelBene (D-Wash.), Mike Kelly (R-Penn.), Ami Bera, M.D., (D-Calif), and Larry Bucshon, M.D., (R-Ind). The Better Medicare Alliance and the American Hospital Associations are among the 500 organizations that have endorsed the bill.
Health plans use prior authorization to ensure that patients receive clinically appropriate treatments and help control the costs of care, but a recent report by the Office of Inspector General found that MA organizations sometimes delayed or denied MA beneficiaries’ access to services even when the requests met Medicare coverage rules.
Providers complain that the paperwork associated with prior authorization is a burden and say they spend an average of 13 hours a week on completing the necessary requirements. Thirty-four percent of physicians report that prior authorization has led to a serious adverse event for a patient in their care.
“The Improving Seniors’ Timely Access to Care Act will make it easier for seniors to get the care they need by cutting unnecessary red tape in the health care system,” said DelBene.
Senator Roger Marshall, M.D., the bill’s lead in the Senate, said the legislation is the most supported health care bill in the entire Congress both in the number of 320 cosponsors and more than 500 national and state endorsing organizations. “The support underscores our legislation’s significance to patients, health care providers, and innovators in medicine. Today marks an important step forward, but our work is not finished. I urge Senate leadership to work with me in moving the Improving Seniors’ Timely Access to Care Act to the President’s desk.”