House committee advances bill reforming MA prior authorization

Photo: John Baggaley/Getty Images

The House Ways and Means Committee on Wednesday convened a markup session regarding a bipartisan bill, "Improving Seniors' Timely Access to Care Act of 2022," which seeks to modernize the way Medicare Advantage plans and healthcare providers use prior authorization.

Health insurers, including many MA plans, require providers to obtain prior authorization for certain medical treatments or tests before they can provide care to their patients. Prior authorization can play a role in ensuring people receive clinically appropriate treatments and help control the cost of care.

But patients and some providers say it can be misused, resulting in increased administrative burdens for providers and robbing them of time with the patient – and in some cases delaying needed medical interventions.

Representatives Suzan DelBene, D-Wash.; Mike Kelly, R-Pa.; Ami Bera, D-Calif.; and Larry Bucshon, R-Ind., introduced the bill last year. Wednesday's markup session provided an opportunity for lawmakers to make amendments before sending it to the floor. No amendments were added to the bill.

DelBene told the committee that the "cumbersome and antiquated" prior authorization process is "too often getting in the way."

"Delayed approvals mean patients fall through the cracks," she said. "This bill avoids that."

The legislation has received support from about 500 industry organizations, including the American Medical Association and the American Hospital Association.

WHAT'S THE IMPACT?

In 2018, the U.S. Department of Health and Human Services' Office of the Inspector General raised concerns after an audit revealed that MA plans ultimately approved 75% of requests that were originally denied.

Health plans and providers have agreed that the prior authorization process can be improved and agreed on principles in a 2018 consensus statement.

The bill would seek to establish an electronic prior authorization process; require HHS to establish a process for "real-time decisions" for items and services that are routinely approved; improve transparency by requiring MA plans to report to the Centers for Medicare and Medicaid Services on the extent of their use of prior authorization and the rate of approvals or denials; and encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.

"When seniors need critical medical care, doctors and other healthcare providers should be spending their time working with patients instead of going back and forth on requests that should be electronic, standardized and eventually automated," said DelBene. "The majority of the healthcare community agrees that prior authorization needs to be reformed."

THE LARGER TREND

An April OIG report found Medicare Advantage Organizations (MAOs) sometimes delayed or denied MA beneficiaries' access to services, even though the prior authorization requests met Medicare coverage rules.

Examples of healthcare services involved in denials that met Medicare coverage rules included advanced imaging services such as MRIs and stays in post-acute facilities, such as inpatient rehabilitation facilities, according to the report.

MAOs denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules, it said. Among the payment requests that MAOs denied, 18% met Medicare coverage rules and MAO billing rules, the report said.
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com