Several high-profile health care advocates are coming out in support of the House’s decision Wednesday to pass a bill to reform prior authorization for Medicare Advantage plans.
the bill, HR 3173, establishes three requirements: Medicare Advantage (MA) plans must establish an electronic prior authorization program that meets certain standards, such as providing real-time decisions for requests for routine services; publishes prior authorization information each year, including the percentage of approved requests and the average response time; and meet the quality and timeliness standards of the Centers for Medicare & Medicaid Services for prior authorization.
The prior authorization process determines whether a payer will cover a health service. Many see it as a time-consuming barrier to accessing care. Almost all MA enrollees, or 99%, are in plans that require prior authorization for some services, recently report by the Kaiser Family Foundation.
Changing the process has support from both sides of the aisle: The bill was sponsored by Reps. Suzan DelBene (D-WA), Mike Kelly (R-PA), Ami Bera (D-CA) and Larry Buckshon (R-IN).
The Better Medicare Alliance, a MA advocacy organization, celebrated the House’s decision to pass the Improving Seniors’ Timely Access to Care Act.
“The Improving Seniors’ Timely Access to Care Act is common sense, bipartisan legislation to further raise the bar for care delivery in Medicare Advantage — where seniors experience already a 94% satisfaction rate, nearly $2,000 in annual consumer savings, additional benefits, and improved health outcomes, just to name a few. By making this legislation law, Medicare Advantage will be even stronger for current and future enrollees,” said Mary Beth Donahue, BMA president and CEO, in statement.
The American Hospital Association (AHA), a hospital advocacy group, also supported the bill. The AHA has been a longtime supporter of prior authorization reform recently publishing house scathing report that claims commercial insurers’ use of the process burdens providers and delays patient care. He cites the 2021 American Medical Association research of more than 1,000 doctors, which found 88% of doctors describe the burden associated with prior authorization as high or extremely high.
“This legislation takes important steps to reduce the burden and complexity of prior authorization requirements imposed by Medicare Advantage plans,” said Stacey Hughes, AHA executive vice president, in statement. “These regulations will help Medicare patients get timely access to the care they need while reducing the strain on our already taxed health care workforce.” AHA is encouraged by the Senate’s support of the companion legislation and urges them to take action on these critical protections.
The lobbying group representing the U.S. insurance industry neither criticized nor celebrated the bill’s passage in the House.
“Doctors and clinicians provide important care and life-saving treatment — and they agree that we must all work together to avoid care that is inappropriate, unnecessary and more expensive,” said David Allen, spokesman for American Health Insurance Plans (AHIP ), in a statement. “Prior authorization is an important decision that ensures that the care patients receive through Medicare Advantage coverage is safe, effective, proven and affordable. And Medicare Advantage provides just that. Protecting the value of MA is essential as we work together to further improve prior authorization processes. We look forward to further engagement on this issue as the bill now moves forward in the Senate.
Although AHIP views prior authorization as a way to reduce costs and avoid unnecessary care, the process still needs improvement, said Dr. A. Mark Fendrick, director of the Center for Value-Based Insurance Design at the University of Michigan.
“With studies display that up to a quarter of all health care spending is wasted on services without patient benefit, we need a robust, next-generation prior authorization program to deter low-cost and even harmful care while protecting access to needed treatment and effective therapies ” said Fendrick in a statement. “But we must not accept a false choice between securing the core function of prior authorization and modernizing the process. The Improving Timely Access to Care for Older Adults Act uses the latest technology to ensure real-time decision making and a 21st century prior authorization system that benefits both patients and providers. “
The bill now goes to the Senate for decisions. If passed there, it would require President Joe Biden’s signature to be signed into law.
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