Bipartisan group brings back prior authorization reform legislation in Congress

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Prior authorization reform legislation is back in Congress for another consideration.

A group of bipartisan lawmakers, including some doctors in Congress, have introduced the latest version of the Improving Seniors Timely Access to Care Act. The bill has had strong bipartisan support and widespread backing from health care and medical organizations. An earlier version passed in the House, but it stalled in the Senate and has never made it to the president’s desk for a signature.

Rep. Suzan DelBene (D-Washington)

Supporters hope this time will be different as more Americans encounter delays in care caused by requirements set up by insurance companies to approve payment for treatments and medicines before patients get them.

“While we’ve made progress streamlining prior authorization, this practice still results in too many seniors facing harmful delays in their care and providers spending too much time justifying common procedures instead of treating patients,” sponsor Rep. Suzan DelBene (D-Washington) said in a news release.

Sen. Roger "Doc" Marshall (R-Kansas)

Sen. Mark R. Warner (D-Virginia)

“Our bipartisan bill builds on that progress by bringing the system into the 21st century and ensuring seniors can access the timely, high-quality care they deserve,” she said. “When seniors are fighting deadly illnesses, they shouldn’t have to fight their insurance company.”

Co-sponsors are Rep. Mike Kelly R-Pennsylvania), Rep. Ami Bera, MD (D-California), and John Joyce, MD (R-Pennsylvania), in the House. Sen. Roger “Doc” Marshall, MD (R-Kansas) and Sen. Mark Warner (D-Virginia) introduced companion legislation in the Senate and published a joint announcement about it, with comments from numerous other senators and supporters.

Prior authorization needed

Many physicians, other clinicians and patients have become frustrated with the processes that insurance companies use, and the legislators offered their own explanation about why it’s an administrative headache.

“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,” their announcement said. “However, the current system often results in multiple faxes or phone calls by clinicians, which takes precious time away from delivering care. Prior authorization continues to be the number one administrative burden identified by health care providers, and nearly three out of four Medicare Advantage enrollees are subject to unnecessary delays due to the practice.”

Prior auths collectively can affect millions of patients — as of January, the U.S. Centers for Medicare & Medicaid Services (CMS) tallied 34.9 million enrollees in Medicare Advantage, or 51% of the total of 68.5 million Medicare enrollees, with 33.6 million people enrolled in traditional Medicare.

What are the changes?

The bill would involve Medicare Advantage insurers and the authority of the U.S. Department of Health and Human Services (HHS). The lawmakers said the bill would:

• Establish an electronic prior authorization process for Medicare Advantage plans including a standardization for transactions and clinical attachments.
• Increase transparency around Medicare Advantage prior authorization requirements and its use.
• Clarify HHS’ authority to establish timeframes for electronic prior authorization requests including expedited determinations, real-time decisions for routinely approved items and services, and other prior authorization 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-prior authorization process.

The lawmakers cited two government reports on prior authorizations. A September 2018 study by HHS’ Office of Inspector General (HHS-OIG) revealed Medicare Advantage plans ultimately approved 75% of requests that were originally denied. In April 2022, HHS released a report finding that MA plans incorrectly denied beneficiaries access to services even though they met Medicare coverage rules.

“The bill focuses on holding Medicare Advantage plans accountable and transparent to the American public,” their announcement said.

What’ll it cost us?

In the past, some in Congress had concerns about a potential pricetag for the procedural changes. For the newest version, the legislators said in 2024, the Congressional Budget Office determined the bill would result in a zero cost to American taxpayers.

“Patients would receive better access to necessary care, and providers would see a significant regulatory burden,” the announcement said.

In their announcement, the lawmakers noted in January 2023, HHS finalized regulations that made many of the changes proposed in the legislation. They still want the congressional stamp of approval to codify the regulations so no future administration could undo them.