House passes reform to Medicare Advantage prior authorizations

Support already strong in Senate, so vote could happen this year.

The U.S. House of Representatives unanimously passed legislation that would streamline the prior authorization (PA) process used for Medicare Advantage patients.

The Improving Seniors’ Timely Access to Care Act, which has earned strong support from medical organizations, will move to the Senate for consideration. It already has strong bipartisan support there.

The law proposes to make it easier for senior patients to get care and improve health outcomes by modernizing the “antiquated” prior authorization process, which often still requires using facsimile machines to send documents to insurance companies, said the announcement from sponsoring lawmakers. Nationally, about 28 million seniors use Medicare Advantage plans for their health insurance.

The legislation was led in the House by Representatives Suzan DelBene, D-Washington, Mike Kelly R-Pennsylvania, Ami Bera, MD, D-California, and Larry Bucshon, MD R-Indiana. It has more than 320 cosponsors and the endorsement of over 500 organizations.

“Seniors and their families should be focused on getting the care they need, not faxing forms multiple times for procedures that are routinely approved. This takes away valuable time from providers who on average spend 13 hours a week on administrative paperwork related to prior authorization,” the representatives said in a joint statement published Sept. 14. “The Improving Seniors’ Timely Access to Care Act will make it easier for seniors to get the care they need by cutting unnecessary red tape in the health care system. We urge the Senate to quickly take up this legislation and get it to President Biden’s desk.”

The bill would:

  • Establish an electronic prior authorization process.
  • Require the U.S. Department of Health & Human Services (HHS) to establish a process for “real-time decisions” for items and services that are routinely approved.
  • Improve transparency by requiring Medicare Advantage plans to report to the Centers for Medicare & Medicaid Services on the extent of their use of prior authorization and the rate of approvals or denials.
  • Encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.

The bill has bipartisan support in the Senate, where sponsor Sen. Roger “Doc” Marshal, MD, R-Kansas, called it “the most supported health care bill in the entire Congress.”

“For nearly four years, my colleagues and I have worked tirelessly on this bipartisan, bicameral legislation to modernize Medicare Advantage to better serve America’s seniors,” Marshall said in a news release. “The support underscores our legislation’s significance to patients, health care providers, and innovators in medicine.”

The House approval “marks an important step forward, but our work is not finished,” he said. “I urge Senate leadership to work with me in moving the Improving Seniors’ Timely Access to Care Act to the President’s desk.”

American Medical Association (AMA) President Jack resneck Jr., MD, called passage of the bill a “rare show of bipartisan support.”

“The House recognized that prior authorization is an insurance companies’ practice that is overused, costly, opaque, burdensome to physicians, and harmful to patients due to delays in care,” Resneck said in a statement published by AMA. “The American Medical Association is committed to fixing prior authorization and made doing so a central plank of our Recovery Plan for America’s Physicians

“Now that the House has passed this legislation, we urge the Senate to do likewise,” Resneck said. “There is a Senate companion bill that also has bipartisan support. While health care legislation often divides Congress, here is a bipartisan way to improve patient health. The tea leaves suggest this can get done this year.”