New Bill Targets Prior Authorization

Organizations call for reform in Medicare Advantage

A COALITION OF about 370 organizations is calling for prior authorization automation and reform in Medicare Advantage. The groups want Congress to pass the Improving Seniors’ Timely Access to Care Act of 2019 introduced by Reps. Suzan DelBene (D-WA), Mike Kelly (R-PA), Roger Marshall, MD (R-KS), and Ami Bera, MD (D-CA). The bipartisan legislation aims to streamline and standardize the process in Medicare Advantage.

Ninety-one percent of providers reported care delays stemming from prior authorizations, according to the American Medical Association’s 2018 survey of 1,000 practicing physicians. “Medicare Advantage is the right place to start streamlining the process,” the organizations wrote. The bill requires electronic transmission of prior authorization requests and responses and a real-time process for items and services that typically require a prior authorization. Plans would be required to report on their prior authorization use and rate of approvals or denials. The bill also requires health plans to adopt prior authorization programs that adhere to evidence-based medical guidelines and are reviewed annually.

About one-third of all Medicare beneficiaries, or 22 million individuals, are currently enrolled in Medicare Advantage plans, and almost four out of five enrollees belong to plans that require prior authorization for some services. A 2018 HHS Office of Inspector General report showed that Medicare Advantage plans overturn 75% of prior authorization and claim denials, indicating “widespread and persistent problems.”

The Centers for Medicare and Medicaid Services has announced plans to address prior authorization under its Patients Over Paperwork initiative, and has met with the AMA to gather data. In these discussions, the AMA stressed the lack of meaningful change in prior authorization programs across commercial insurers, despite the release in early 2018 of the Consensus Statement on Improving the Prior Authorization Process, an important agreement between health care professional associations and national insurer trade organizations.

The AMA noted the lack of progress on this issue. Given this stagnation, Medicare should serve as a leader and model meaningful prior authorization reforms for commercial insurers by developing a comprehensive strategy that addresses all areas of the Consensus Statement, the AMA said