MA prior authorization bill gets bipartisan support ahead of star ratings release
Bill would establish an electronic prior authorization process for MA plans, including standardization for transactions and clinical attachments.
Photo: Joe Daniel Price/Getty Images
As Medicare Advantage insurers await the release of the 2025 MA star ratings later today, lawmakers are looking to streamline plans' use of prior authorization due to concerns of high denials.
The Improving Seniors' Timely Access to Care Act, which unanimously passed the House last month, has received bipartisan majority support in the House from 218 cosponsors, according to Rep. Suzan DelBene, D-Wash.
It also has the support of over 440 national and state organizations representing patients, physicians, MA plans, hospitals and other key healthcare stakeholders, DelBene said.
The legislation would streamline and standardize the way Medicare Advantage plans use prior authorization by establishing an electronic prior authorization process, including standardization for transactions and clinical attachments.
The bill would clarify the authority of Centers for Medicare and Medicaid to establish time frames for electronic prior authorization requests including expedited determinations, real-time decisions for routinely approved items and services, and other prior authorization requests.
WHY THIS MATTERS
The Department of Health and Human Services raised concerns of MA prior authorization rates after an audit revealed that these plans ultimately approved 75% of requests that were originally denied.
HHS released a report finding that MA plans incorrectly denied beneficiaries' access to services even though they met Medicare coverage rules.
Congressional scrutiny of Medicare Advantage plans comes at a time when insurers are facing lower margins in the market and higher thresholds for obtaining stars that would earn them quality bonus payments.
UnitedHealthcare has sued the Centers for Medicare and Medicaid Services over its star ratings downgrade.
Humana is challenging CMS over its lower results.
Plans are given the 2025 results prior to the public release of the 2025 Medicare Advantage Star Ratings, which is expected to be released as early as today.
THE LARGER TREND
Prior authorization continues to be among the top administrative burdens identified by healthcare providers.
ON THE RECORD
DelBene said, "With over 33 million Americans enrolled in Medicare Advantage, modernization of the prior authorization process is long overdue. Lawmakers on both sides of the aisle, hundreds of healthcare organizations, and Americans from all corners of the country agree – streamlining this process will allow our nation's seniors to receive the care they are entitled to more efficiently."
Email the writer: SMorse@himss.org
