MIL-OSI USA: DelBene Introduces Updated Prior Authorization Reform Bill

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Source: United States House of Representatives – Congresswoman Suzan DelBene (1st District of Washington)

Today, Congresswoman Suzan DelBene (WA-01) introduced an updated Improving Seniors’ Timely Access to Care Act along with Representatives Mike Kelly (PA-16), Larry Bucshon, M.D. (IN-08) and Ami Bera, M.D. (CA-06) and Senators Roger Marshall, M.D. (KS), Kyrsten Sinema (AZ), John Thune (SD), and Sherrod Brown (OH).

The bipartisan legislation would help get seniors the care they need and allow health care providers to spend more time with patients by streamlining and modernizing the prior authorization process under Medicare Advantage. In 2023, nearly 31 million seniors were enrolled in a Medicare Advantage plan, including more than 730,000 in Washington.

“We’ve made important incremental headway in helping seniors get the medical care they deserve with the administration’s prior authorization regulations. However, we must go further and enshrine these advancements into law. By passing the bipartisan, bicameral Improving Seniors’ Timely Access to Care Act, we can make it much easier for seniors to receive the care they’re entitled to while also alleviating unnecessary burdens on physicians and hospitals,” said Congresswoman Suzan DelBene (WA-01).  

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. 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.

In recent years, the U.S. Department of Health and Human Services (HHS) revealed that Medicare Advantage plans ultimately approved 75% of requests that were originally denied. More recently, HHS released a report finding that MA plans incorrectly denied beneficiaries access to services even though they met Medicare coverage rules.

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 e-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 Improving Seniors’ Timely Access to Care Act unanimously passed the House last Congress and was cosponsored by a majority of members in the Senate and House of Representatives. In January, HHS finalized regulations that made many of the changes proposed in the legislation. The bill would codify these wins to ensure no future administration could undo them and make further improvements.

The bill is sponsored by 130 members of the House of Representatives and 42 members of the Senate. It is supported by over 370 national and state organizations representing patients, physicians, Medicare Advantage plans, hospitals, and other key stakeholders in the health care industry.

The bill text can be found here and a section-by-section can be found here.