Congress Debates Bill to Automate Prior Authorization in Medicare Advantage Plans

Recently the House of Representatives’ Small Business Committee convened for a hearing on utilization management and barriers to care in small medical practices. In particular this hearing focused on the application of prior authorization within Medicare Advantage (MA) plans and the associated challenges faced by patients and providers of services due to prior authorization requirements.

The underlying theme of the hearing was support for H.R. 3107, the Improving Seniors’ Timely Access to Care Act, a bill that would automate the prior authorization process in Medicare Advantage plans. This automation would be through electronic submission of prior authorization requests with real-time determinations by the MA plans. The legislation encourages integration of the electronic prior authorization submission into electronic medical record systems. The Secretary of Health and Human Services would be tasked with developing standards in conjunction with stakeholder input. In addition, certain transparency requirements would be put in place. These include:

  • A list of services and items subject to prior authorization;
  • The percentage of prior authorization requests approved during the previous plan year by the plan for each item and service;
  • The percentage of requests that were initially denied and then subsequently appealed, and the percentage of such appealed requests that were overturned for each such item and service; and
  • The average amount of time elapsed from request submission to determination

This legislation would have impact on all provider types that contract with Medicare Advantage plans that are subject to prior authorization.

Testifying at the hearing were four different physician-focused trade associations; Radiation Oncologists, Anesthesiologists, Family Physicians, and Dermatologists. Each of the four witnesses outlined the challenges that prior authorization places on their practice, as well as the impact the requirement has on their patients. In particular witnesses focused on delays in care, inappropriate request denial, non-licensed professionals reviewing requests, and the prior authorization requirement being used as an unnecessary delay tactic to deter provision of care. In one testimony a 2018 report from the Office of the Inspector General (OIG) evaluating appeal outcomes in Medicare Advantage Organizations (MAO) was quoted with “MAOs may have an incentive to deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits.”

The National Association for Home Care and Hospice will continue to monitor this legislation for updates and further activity within the Congress.