A Step Closer to Passage of Federal Prior Authorization Legislation

In a few short months, the 117th U.S. Congress will end, putting pressure on lawmakers to address a multitude of legislative priorities, while contending with the political pressures of a fast-approaching general election.

The good news is that in a seemingly endless Congressional environment of gridlock, healthcare-related proposals may see some slow, but steady progress.

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In May 2021, the House introduced the Improving Seniors’ Timely Access to Care Act. This legislation sets out to expedite prior authorization requests and quickly clear care and services that are routinely approved for patients covered under a Medicare Advantage (MA) plan. A major provision of this proposed legislation requires MA plans to create an electronic prior-authorization process, aimed at alleviating a major source of administrative burden for providers. In addition to requiring electronic prior authorization for MA plans, the bill would:

Require the Department of Health and Human Services to create a process for “real-time decisions” on items and services that commonly get approved;

Require MA plans to report to the Centers for Medicare & Medicaid Services on their use of prior authorization and their rate for approvals and denials; and

Entice plans to adopt evidence-based medical guidelines when consulting with physicians over prior authorization requests.

In September 2022, the House passed this legislation in a bipartisan way, including key co-sponsorships from physicians in Congress: Ami Bera, MD, D-California, and Larry Bucshon, MD, R-Indiana.

When the bill passed out of the House, a new provision was added. It requires MA plans to report how they use prior authorization and the rate that such requests are approved and denied. This new provision arose out of an investigation by the Department of Health and Human Services' Office of Inspector General, which found that MA plans were denying prior authorization claims for services that met Medicare’s coverage requirements. This investigation and resulting additional requirement are significant given that close to half of all Medicare beneficiaries are enrolled in MA plans, with more expected in the coming years. 

The new iteration of the Improving Seniors’ Timely Access to Care Act has moved over to the Senate and is awaiting action. Although lawmakers have many other legislative interests, advancing reform on prior authorization by full passage of this bill would seem a favorable win for both sides if achieved before the close of this congressional session.     

Gabriela Villanueva is CAP’s Government and External Affairs Analyst. Questions or comments related to this article should be directed to GVillanueva@CAPphysicians.com.