Medicare Advantage Prior Authorization Bill Nears Passage

It may soon become easier for providers to obtain prior authorization decisions from Medicare Advantage Plans under legislation passed through Congress.

Last week, a key House committee moved forward a bill that would ease the pre-clearance requirements for Medicare Advantage operators, which providers and patients say are long overdue for change. Groups lobbying for the bill hope it will be included in a larger legislative package by the end of the year.

The bill would require Medicare Advantage insurers to create electronic pre-authorization programs that provide real-time decision making for certain goods and services. Federal regulators will establish the definition of “real time decision” through formal rulemaking.

Insurers will also be required to comply with transparency requirements by annually providing lists of items and services subject to prior authorization, data on authorization denials and approvals, and disclosure of information about the decision-making software they use. Insurers will also share some of this information with providers, vendors and beneficiaries.

In addition, insurers will have to adopt beneficiary protection standards that allow changes to results-based prior authorization rules for providers, continuity of care for people moving between insurance coverages, and more.

Legislators first introduced the Improve Timely Access to Care for Older People Act in 2019. The legislation is now closer than ever to passing, following its approval by the House Ways and Means Committee last week. Rep. Susan DelBen (R-Wash.) is the lead sponsor of the House of Representatives, and Senator Roger Marshall (R-Kansas) has introduced a companion bill in the upper house, where the Finance Committee has not yet considered it.

Supplier groups supported this measure. Streamlining the process “will reduce the wide variety of prior authorization practices that are frustrating for both patients and providers,” Stacey Hughes, executive vice president of the American Hospital Association, wrote to the committee last month.

Increased federal oversight of Medicare Advantage prior authorization practices has fueled momentum on Capitol Hill. In April, inspectors from the Department of Health and Human Services reported that some Medicare Advantage insurers were denying needed medical care. According to the Office of the HHS Inspector General, approximately 13% of prior authorization requests that get these plans denied would be covered by Medicare.

The bill has more than 300 cosponsors in the House of Representatives and nearly 40 in the Senate. Supporters are looking for a legislative remedy for the measure, said Peggy Tai, a health lobbyist who runs the Regulatory Assistance Coalition, an umbrella group that includes medical organizations such as the American College of Surgeons, the American Academy of Family Medicine and the Medical Group Management Association. .

“It says on the wall that transparency is what healthcare should be,” Taige said.

The insurance industry, which argues that prior authorization is needed to improve efficiency and safety, has not strongly opposed the bill. The Better Medicare Alliance, which lobbies for the Medicare Advantage policy, even officially endorsed it.

“The Better Adults’ Timely Access to Care Act is a sound decision based on the work the Medicare Advantage community has done to make it easier for older people to get prior authorization,” Mary Beth Donahue, president of the Better Medicare Alliance, said in a press release. released in May.

AHIP, the insurers’ trade association, supports electronic pre-authorization. The organization released a report outlining how insurance companies have improved pre-approvals since 2018, the same day the Ways and Means Committee flagged the bill.

“This sets the stage for a bill that is bipartisan, bicameral, with huge support to move forward. While many other bills are desperate to get into the final legislature at the end of the year, this one is well positioned to do so,” Taige said.

The Senate is currently focused on passing a domestic policy bill that would expand health insurance exchange subsidies and regulate prescription drug prices, and prior authorization reforms are unlikely to be part of the effort. The upcoming midterm congressional elections are also getting a lot of legislators’ attention. But Congress may turn to other priorities before the end of the session, including during the lame duck period between Election Day and the convening of a new Congress in January, said Claire Ernst, MGMA’s director of government affairs.

“I would hope the previous authentication could be migrated as soon as possible, but I wouldn’t be surprised if it was a lame duck situation either,” Ernst said. “Now all eyes are fixed on intermediate dates.”

However, the Congressional Budget Office has yet to evaluate the Act to Improve Timely Access to Health Care for Older Adults. Some legislators may be waiting for a budget estimate before moving forward with the bill. Council on Affordable Healthcare Quality Index 2021, which tracks the use of electronic transactions by providers and health plans, found that the healthcare industry could save $437 million a year by switching to electronic pre-approvals. The report’s findings are not limited to Medicare Advantage.

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