The group are urging CMS to enhance its proposed rule and build on the regulations for the administrative process.
CMS has released its proposed rule to streamline prior authorization in government-sponsored health insurance programs, but a contingent of lawmakers want the agency to go further.
A bipartisan group of 233 representatives and 61 senators penned a letter asking CMS to both expand the proposed rules and promptly finalize the changes to improve the administrative process in Medicare Advantage (MA), Medicaid, and Affordable Care Act exchange plans.
Specifically, the lawmakers are urging CMS to:
- Establish real-time electronic prior authorization decisions for routine services.
- Require plans to respond to prior authorization requests within 24 hours for urgent care.
- Require detailed transparency metrics.
Combined with the Improving Seniors' Timely Access to Care Act, the prior authorization regulations would put in place electronic prior authorization processes for MA plans, accelerate prior authorization time frames, reduce administrative burden on providers and health plans, increase transparency around prior authorization requirements, and expand beneficiary protections.
"We urge CMS to promptly finalize and implement these changes to increase transparency and improve the prior authorization process for patients, providers, and health plans," the lawmakers stated. "We are pleased that these proposed rules align with the bipartisan, bicameral Improving Seniors' Timely Access to Care Act, which proposes a balanced approach to prior authorization in the [Medicare Advantage] program that would remove barriers to patients' timely access to care and allow providers to spend more time treating patients and less time on paperwork."
Prior authorization has particularly been a problem in MA. Despite longstanding concerns over the administrative process in the private program, a recent survey by the Medical Group Management Association found that little progress has been made. Of the medical groups surveyed, 84% said prior authorization requirements in MA increased in the past 12 months, with less than 1% reporting requirements had decreased.
With MA continuing to experience consistent growth, it's imperative that its expanding membership have access to necessary when they need it.
Jay Asser is the contributing editor for strategy at HealthLeaders.
A bipartisan group of 233 representative and 61 senators have put forth to CMS additional prior authorization regulations in Medicare Advantage and other government-sponsored plans.
The lawmakers want the agency to establish real-time electronic prior authorization, require plans to respond to prior authorization request within 24 hours, and require transparency metrics.