Establishing an electronic prior authorization process and requiring HHS to establish a process for "real-time decisions" for items and services that are routinely approved are two ways a new bill aims to streamline the way Medicare Advantage plans use prior authorization.
The burden of prior authorizations might be lessened soon thanks to new legislation with 227 cosponsors in the U.S. House of Representatives.
The Improving Seniors' Timely Access to Care Act would streamline the way Medicare Advantage plans use prior authorization while also increasing oversight and transparency, according to a statement from Representative Suzan DelBene (WA-01).
The bill would:
- Establish an electronic prior authorization process
- Require HHS to establish a process for "real-time decisions" for items and services that are routinely approved
- Require Medicare Advantage plans to report to Centers for Medicare & Medicaid Services (CMS) on the extent of their use of prior authorization and the rate of approvals or denials
- Encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians
Although health plans and providers agreed on principles to improve prior authorization in a 2018 consensus statement, three years later, the prior authorization process is as arduous as ever.
A Medical Group Management Association MGMA Stat poll earlier this year asked medical groups: "How did payer prior authorization requirements change since 2020?"
The vast majority (81%) said they increased, 17% said they stayed the same, and only 2% said they decreased.
In fact, many respondents said they had to hire additional full-time staff to handle prior authorization work.
An American Medical Association survey revealed additional prior authorization hardships.
It found that:
- 94% of physicians report prior authorization-related care delays
- 79% report that prior authorization can at least sometimes lead to treatment abandonment
- 32% report that prior authorization criteria are rarely or never evidence-based
- 30% report that prior authorization has led to a serious adverse event for a patient in their care
- 21% report that prior authorization has led to a patient's hospitalization
- 18% report that prior authorization has led to a life-threatening event or required intervention to prevent permanent impairment or damage
- 9% report that prior authorization has led to a patient's disability/permanent bodily damage, congenital anomaly/birth defect or death
- 85% describe the burden associated with prior authorization as high or extremely high
"Paperwork should never get in the way of seniors accessing timely, critical care. Prior authorization is an important tool, but we need to bring it into the 21st century so that our seniors get the medical attention they need when they need it," DelBene said in a statement.
Alexandra Wilson Pecci is an editor for HealthLeaders.