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Speed up Medicare Advantage prior authorizations now, lawmakers tell CMS

Article

Bipartisan group of senators, representatives urge regulators to improve process for patients, physicians.

medicare advantage concept: © wladimir1804 - stock.adobe.com

© wladimir1804 - stock.adobe.com

Medicare regulators can’t act fast enough to streamline prior authorizations (PAs) for care for older patients, according to federal lawmakers.

A bipartisan group of senators and representatives signed letters to the U.S. Department of Health and Human Services (HHS) and its Centers for Medicare & Medicaid Services (CMS) urging them “to promptly finalize and implement these changes to increase transparency and improve the prior authorization process for patients, providers, and health plans.”

When used appropriately, PAs are “an important tool for payers to manage costs and ensure program integrity,” said the senators’ letter to HHS Secretary Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure.

But the PA process needs to happen faster for patients and with less paperwork for physicians, the lawmakers said.

Rule changes

Medicare’s proposed rules align with the Improving Seniors’ Timely Access to Care Act, which was approved in the House last year. That bill had bipartisan support in the Senate, along with backing from more than 500 health care stakeholder organizations, but it never got to a vote in the Senate.

CMS announced the proposed rule changes in December 2022 and collected public comments through March this year. The senators’ letter said the CMS rule changes would:

  • Establish an electronic PA process for Medicare Advantage (MA), with real-time decisions for services that are approved routinely.
  • Accelerate PA decision time frames, including a 24-hour deadline for responses for urgently needed care.
  • Reduce administrative burdens for providers and health plans.
  • Increase transparency around PA requirements and clinical information needed for decisions.
  • Expand beneficiary protections to improve patient experiences and outcomes.

In Congress

At least three of the signers are physicians: Rep. Ami Bera, MD, D-California; Rep. Larry Bucshon, MD, R-Indiana; and Sen. Roger “Doc” Marshall, MD, R-Kansas. Marshall and Rep. Suzan DelBene, D-Washington, announced the letter with support from 233 representatives and 61 senators.

They noted technology can be an ally in the PA process as the health insurance industry aims to integrate “real-time decisions through automation and artificial intelligence from end-to-end.” There is software to do that and “robust evidence” that real-time decisions will produce cost savings for health care providers and insurers, the senators’ letter said.

Even with technology, the laments of physicians and patients, and legislative support, at least one study this year found the PA administrative burdens are getting worse over time, not better.

PA improvement would help, but it is not the only change needed in CMS. This month, the American Medical Association (AMA) announced a new campaign to raise physician payment rates that are declining over time due to inflation and other factors.

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Mike Bannon - ©CSG Partners