June 14, 2024
Sens. Roger Marshall, MD, (R-KS), Kyrsten Sinema (I-AZ), John Thune (R-SD), Sherrod Brown (D-OH), and Reps. Mike Kelly (R-PA), Suzan DelBene (D-WA), Larry Bucshon, MD, (R-IN), and Ami Bera, MD, (D-CA) reintroduced the Improving Seniors’ Timely Access to Care Act. The bipartisan, bicameral legislation streamlines the prior authorization process under Medicare Advantage (MA), allowing seniors to get the care they need and helping health-care providers put patients over paperwork.
Prior authorization is a tool health plans use to reduce unnecessary care by requiring health-care providers to get pre-approval for medical services. But it’s not without fault. The current system often results in unconfirmed faxes of a patient’s medical information or phone calls by clinicians, which takes precious time away from delivering quality and timely care. Prior authorization continues to be the #1 administrative burden identified by health-care providers, and three out of four Medicare Advantage enrollees are subject to unnecessary delays due to prior authorization. In recent years, the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS) raised concerns after an audit revealed that Medicare Advantage plans ultimately approved 75% of originally denied requests. More recently, HHS OIG released a report finding that MA plans incorrectly denied beneficiaries access to services even though they met Medicare coverage rules.
Health plans, health-care providers, and patients agree that the prior authorization process must be improved to serve patients better and reduce unnecessary administrative burdens for clinicians. In fact, leading health-care organizations released a consensus statement to address some of the most pressing concerns associated with prior authorization.
Specifically, the bill would:
- Establish an electronic prior authorization process for MA plans, including a standardization for transactions and clinical attachments.
Increase transparency around MA prior authorization requirements and its use. - Clarify CMS’ authority to establish timeframes for e-PA requests, including expedited determinations, real-time decisions for routinely approved items and services, and other PA requests.
- Expand beneficiary protections to improve enrollee experiences and outcomes.
- Require HHS and other agencies to report to Congress on program integrity efforts and other ways to improve the e-PA process further.
This bill is supported by over 370 national and state organizations, including AMDA - The Society for Post-Acute and Long-Term Care Medicine, representing patients, physicians, MA plans, hospitals, and other key stakeholders in the health-care industry.
The text of the bill is available here. A section-by-section summary can be found here.