Bipartisan Bill Reintroduced to Streamline Medicare Advantage Prior Authorization

Sens. Mark Warner (D-VA) and Roger Marshall, MD (R-KS), have reintroduced the Improving Seniors’ Timely Access to Care Act (S. 1816), a bipartisan, zero-cost bill designed to improve access to care for the 32.8 million Americans enrolled in Medicare Advantage (MA) plans. The legislation aims to simplify the prior authorization process, a requirement for medical service pre-approvals that providers often describe as burdensome and time-consuming.

The bill proposes to:

• Establish an electronic prior authorization process for MA plans, including standardization for transactions and clinical attachments: Faxes, e-forms, or proprietary web portals run by health plans that do not meet these standards would not qualify as secure electronic transmissions.
• Increase transparency around MA prior authorization and its use: Health plans would now be required to, among other things, report on all items and services subjected to e-PA requirements the previous plan year, the percent and number of requests approved and denied, the percent and number of requests approved or denied utilizing artificial intelligence or machine learning technology, and the average and median amount of time (in hours) that elapsed between the time the request was submitted and when the health plan issued a final decision.
• Clarify HHS’ authority to establish timeframes for electronic prior authorization requests, including expedited timelines for determinations, as well as real-time decisions for routinely approved items, services, and other prior authorization requests: The bill, however, does not mandate any specific deadlines for health plans to issue final decisions on prior authorization requests in order to avoid triggering any costs via a Congressional Budget Office (CBO) analysis often referred to as a “score.”
• Expand beneficiary protections to improve enrollee experiences and outcomes, including allowing for the waiver or modification of PA requirements for contracted providers and suppliers based on past performance and adherence to evidence-based medical guidelines (i.e., Gold Card programs).
• Require that the Department of Health and Human Services and other agencies report to Congress on program integrity efforts and other ways to further improve the electronic prior authorization process.

This reintroduction comes amid longstanding concerns that the current system delays necessary care and overwhelms health-care providers with administrative tasks. Past reports from the Department of Health and Human Services’ Office of Inspector General have highlighted how Medicare Advantage plans have wrongly denied valid claims and later approved 75% of initially rejected requests.

A wide coalition of more than 45 senators from both parties supports the bill, along with House counterparts who introduced companion legislation (H.R. 3514). The bill is endorsed by over 138 health-care organizations, including PALTmed, which has supported previous introductions of the bill and continues to back the effort.