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Representative takes aim at prior authorizations in Medicare, Medicare Advantage

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Article

Legislation that would speed up treatment reviews is piling up. Will Congress or CMS act first?

prior authorization form rx stethoscope: © Maksim Shchur - stock.adobe.com

© Maksim Shchur - stock.adobe.com

A physician lawmaker is joining the fight against prior authorizations (PAs) that bog down medical care, frustrating physicians and patients alike – and sometimes jeopardizing treatments.

Rep. Mark Green, MD (R-Tennessee), announced he has reintroduced the “Reducing Medically Unnecessary Delays in Care Act” to address PAs in Medicare and Medicare Advantage plans. The bill also has changes in store for PAs for prescription drugs under Medicare.

“A physician should be the one determining a patient’s course of treatment. Prior authorization is a roadblock to care – equivalent to a bureaucrat in the waiting room,” Green said in a statement.

“Medicare and Medicare Advantage plan administrators should not be able to exercise a unilateral veto over a doctor’s prescribed treatment,” he said. “It is this kind of red tape that creates frustration for healthcare providers and patients alike. We know that preauthorization leads to delays in care and worse health outcomes for patients – it’s time to put patients first. Preauthorization doesn’t do that.”

The proposed legislation would require that board-certified physicians in relevant specialties make decisions about patient treatment, according to Green’s office.

“It would also direct Medicare, Medicare Advantage, and Medicare Part D plans to comply with requirements that restrictions must be based on medical necessity and written clinical criteria, as well as additional transparency obligations,” his official summary said.

The bill is the latest among calls to reform the process that health insurance companies use for approving health care procedures. The concept appears to have widespread support among lawmakers in the House and Senate, along with physicians and patients, but congressional action has been slow coming.

Green’s legislation gained a statement of support from Medical Group Management Association (MGMA) Senior Vice President of Government Affairs Anders Gilberg. He called it an important step to reform PA in the government health insurance programs.

Earlier this year, MGMA published its findings about PA, from a survey of medical practices. PA is nearly ubiquitous because 95% of respondents treat patients covered by Medicare Advantage plans, and 75% reported increasing numbers of those patients.

Who decides on treatment? A full 72% of medical groups reported the clinicians assigned to complete their peer-to-peer reviews by the plans are not from a relevant specialty to the treatment or disease in question, according to MGMA. That results “in dangerous delays and flat-out denials.”

“The increase in utilization of overly burdensome prior authorization requirements by health plans leaves medical groups struggling to ensure patients continue to maintain access to medically necessary care,” Gilberg said. “MGMA looks forward to working with our partners in Congress to ensure that no health plan can stand in the way of life-saving healthcare simply to increase their bottom lines."

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Mike Bannon - ©CSG Partners