Congress Considers Medicare Advantage Pre-Approval Legislation

Congress Considers Medicare Advantage Pre-Approval Legislation

According to a report from Modern Healthcare, Congress is considering changes to Medicare Advantage that would “crack down on prior authorization tactics insurers use to rein in healthcare costs but can affect how providers care for patients.”

A bi-partisan group of Representatives in the House has reintroduced a bill that aims to “quicken the prior authorization process and require more transparency about how often plans deny providers' requests.”

Prior authorization reform has long been a goal of provider groups like the American Medical Association, which says physicians are increasingly being told to get approval from insurance plans before a patient can access drugs, tests or treatments.

In a survey taken last year by the American Medical Association, 15% of physicians polled said prior authorization requirements always delayed access to necessary care for patients, while 39% said that often happened and 40% said it happened sometimes.

Prior authorization can also have an impact on physician practices, with 85% saying requirements pose a high or extremely high burden, and 40% saying they have staff who exclusively work on getting approval from insurance companies for treatment.

Insurers, on the other hand, argue that prior authorization helps reduce inappropriate care and thus reduces medical costs.

The purpose of the bill is said to be the creation of sensible rules that will result in giving transparency and oversight to the prior authorization process.

Under the bill, Medicare Advantage plans must establish electronic prior authorization programs and provide "real-time decisions" for some services that are routinely approved by insurers, to be determined by the Health and Human Services secretary.

The proposal would require Medicare Advantage plans with prior authorization requirements to submit an annual report to the HHS secretary listing which services require prior approval and how many requests were approved, denied and overturned after initial denials in the previous plan year. They would have to tell HHS the average and median amount of time between the submission of a prior authorization request and a determination from the plan.

Plans would also need to make the information available to providers they contract with and tell beneficiaries and providers the criteria for making prior authorization determinations. The bill encourages insurers to adopt prior authorization programs that adhere to evidence-based medical guidelines.