MIL-OSI USA: Rep. Ami Bera, Colleagues Reintroduce Must-Pass Prior Authorization Reform Bill

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Source: United States House of Representatives – Representative Ami Bera (D-CA)

U.S. Representatives Ami Bera, M.D. (D-CA), Suzan DelBene (D-WA), Larry Bucshon, M.D. (R-IN), Mike Kelly (R-PA), and U.S. Senators Roger Marshall, M.D. (R-KS), Kyrsten Sinema (I-AZ), John Thune (R-SD), and Sherrod Brown (D-OH) reintroduced the Improving Seniors’ Timely Access to Care Act. The bipartisan, bicameral legislation streamlines the prior authorization process under Medicare Advantage (MA) allowing seniors to get the care they need and helping health care providers put patients over paperwork.

“I am pleased to introduce this bipartisan, bicameral legislation that will codify protections to help seniors access the medical care they are entitled to without unnecessary delays and denials due to prior authorization,” said Congressman Ami Bera (D-CA), who previously served as Chief Medical Officer for Sacramento County. “Having practiced in medicine, it is crucial we create an environment where physicians can spend less time with an antiquated prior authorization system and spend more time taking care of their patients.”

“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 (D-WA).  

“An inefficient prior authorization process creates unnecessary paperwork, lag time, and hassle for doctors which can delay critical or life-saving procedures for patients,” said Congressman Dr. Larry Bucshon (R-IN). “As a physician, I believe the best approach to solving challenges with our health care system is to put the patient first.  That’s why I’m proud to join my colleagues in reintroducing the bipartisan Improving Seniors’ Timely Access to Care Act to promote transparency and electronic prior authorization in the Medicare Advantage program. Seniors are counting on us to ensure that they can receive the care they need when they need it.”

“With over 33 million Americans enrolled in Medicare Advantage, modernization of the prior authorization process is long overdue,” said Congressman Mike Kelly (R-PA). “Lawmakers on both sides of the aisle, hundreds of health care organizations, Americans from all corners of the country agree – streamlining this process will allow our Nation’s seniors to receive the care they are entitled to more efficiently. I am proud to reintroduce the Improving Seniors’ Timely Access to Care Act of 2024, which would move the health care sector into the 21st century by giving doctors and Medicare Advantage plans the tools to make health coverage decisions in a timely manner. I was pleased to see this bill unanimously pass the House in the 117th Congress, and I look forward to swift consideration of the bill in this Congress.  I thank my House and Senate colleagues for their years of hard work and for joining me on the reintroduction of this critical legislation.”

“Prior authorization is the number one administrative burden facing physicians today across all specialties, Senator Marshall (R-KS) said. “As a physician, I understand the frustration this arbitrary process is causing health care practices across the country and the headaches it creates for our nurses. With the bipartisan, bicameral, Improving Seniors’ Timely Access to Care Act, we will streamline prior authorization and help improve patient outcomes and access to quality care and life-saving medicine. With the improvements we’ve made there is no reason we should not quickly get this bill signed into law.”

“We’re improving the authorization process so Arizona seniors with Medicare Advantage plans can receive timely and quality care, while lowering the costs and avoiding poorer clinical outcomes related to delayed care. Our bipartisan bill also allows doctors and health care providers to spend less time dealing with red tape and more time with their patients,” said Senator Kyrsten Sinema (I-AZ).

“Modernizing and streamlining the prior authorization process is critical for South Dakota seniors and providers,” said Senator John Thune (R-SD). “This bipartisan legislation would remove unnecessary red tape, make health care more efficient, and ensure patients can access care when they need it.”   

“Right now, too many older Americans enrolled in Medicare Advantage are forced to deal with unnecessary delays when seeking out medical treatment,” said Senator Sherrod Brown (D-OH). “We need to update the Medicare Advantage program so it works better, faster, and is more transparent for patients and providers. By requiring private insurance companies to streamline prior authorization processes electronically, we can ensure providers can quickly access the information they need to treat and care for their patients in a timely manner. ”

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. 

Background

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. But it’s not without fault. The current system often results in unconfirmed faxes of a patient’s medical information or phone calls by clinicians which takes precious time away from delivering quality and timely care. Prior authorization continues to be the #1 administrative burden identified by health care providers, and three out of four Medicare Advantage enrollees are subject to unnecessary delays due to prior authorization. In recent years, the Office of the Inspector General at the U.S. Department of Health and Human Services (HHS) raised concerns after an audit revealed that Medicare Advantage plans ultimately approved 75% of requests that were originally denied. More recently, HHS OIG released a report finding that MA plans incorrectly denied beneficiaries’ access to services even though they met Medicare coverage rules. 

Health plans, health care providers, and patients agree that the prior authorization process must be improved to better serve patients and reduce unnecessary administrative burdens for clinicians. In fact, leading health care organizations released a consensus statement to address some of the most pressing concerns associated with prior authorization. 

Specifically, the bill would:

  • Establish an electronic prior authorization process for MA plans including a standardization for transactions and clinical attachments.

  • Increase transparency around MA prior authorization requirements and its use.

  • Clarify CMS’ authority to establish timeframes for e-PA requests including expedited determinations, real-time decisions for routinely approved items and services, and other PA 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-PA process.

Bill text is available here.

A section-by-section summary can be found here.

MIL OSI USA News