Reps. Kelly, DelBene, Bucshon, Bera applaud milestone for life-saving Medicare Advantage prior authorization bill

WASHINGTON, D.C. -- Today, U.S. Representatives Mike Kelly (PA-16), Suzan DelBene (WA-01), Larry Bucshon, M.D. (IN-08), and Ami Bera, M.D. (CA-06) released the following statement after securing the support of a bipartisan majority for theImproving Seniors' Timely Access to Care Act (H.R. 8702) with over 218 cosponsors in the U.S. House of Representatives. The legislation would improve care for seniors by streamlining and standardizing the way Medicare Advantage (MA) plans use prior authorization and increasing oversight and transparency.

"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 health care organizations, 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. As champions of this legislation, we are grateful to our bipartisan majority of House colleagues for their support, and look forward to working with them to get this critical bill signed into law."

BACKGROUND

Prior authorization is a tool used by health plans to reduce unnecessary care by requiring health care providers to get pre-approval for medical services. However, the current system often results in unconfirmed faxes of a patient's medical information or phone calls by clinicians which takes precious time away from delivering quality and timely care. Prior authorization continues to be the #1 administrative burden identified by health care providers, and three out of four Medicare Advantage enrollees are subject to unnecessary delays due to prior authorization. In recent years, the Office of the Inspector General at the U.S. Department of Health and Human Services (HHS) raised concerns after an audit revealed that Medicare Advantage plans ultimately approved 75% of requests that were originally denied. More recently, HHS OIG released a report finding that MA plans incorrectly denied beneficiaries' access to services even though they met Medicare coverage rules.

Health plans, health care providers, and patients agree that the prior authorization process must be improved to better serve patients and reduce unnecessary administrative burdens for clinicians. In fact, leading health care organizations released a consensus statement to address some of the most pressing concerns associated with prior authorization.

Specifically, the bill would:

• Establish an electronic prior authorization process for MA plans including a standardization for transactions and clinical attachments.
• Increase transparency around MA prior authorization requirements and its use.
  Clarify CMS' authority to establish timeframes for e-PA requests including expedited determinations, real-time decisions for routinely approved items and services, and other PA requests.
• Expand beneficiary protections to improve enrollee experiences and outcomes.
• Require HHS and other agencies to report to Congress on program integrity efforts and other ways to further improve the e-PA process.

The Improving Seniors' Timely Access to Care Act unanimously passed the House in the 117th Congress and was cosponsored by a majority of members in the Senate and House of Representatives.

Bill text is available here.

A section-by-section summary can be foundhere.

This bill is supported by over 440 national and state organizations representing patients, physicians, MA plans, hospitals, and other key stakeholders in the health care industry. To see the list as of today, click here.