ACR: Proposed legislation could eliminate prior authorization ‘hurdles’ in Medicare Advantage

Paula Marchetta

The American College of Rheumatology has applauded a proposed federal bill that would amend the Social Security Act to regulate the use of prior authorization for patients with Medicare Advantage plans.

The bill, H.R. 3107, was introduced in the U.S. House of Representatives, and referred to the Ways and Means Committee and Committee on Energy and Commerce on June 5. It is sponsored by Rep. Suzan DelBene, D-Wash., and cosponsored by representatives Mike Kelly, R-Pa., Roger Marshall, R-Kan., and Ami Bera, D-Calif.

“For far too long, patients have faced unnecessary and unreasonable care delays due to insurers’ overzealous use of prior authorization,” Paula Marchetta, MD, MBA, president of the ACR, said in a press release. “This practice creates significant burdens for physicians and can put patient’s health in jeopardy. We applaud Congressional leaders for standing up to ensure America’s Medicare beneficiaries are able to get the care they need and deserve.”

 
The bill would amend the Social Security Act to regulate the use of prior authorization for patients with Medicare Advantage plans, according to the ACR.
Source: Shutterstock

The text of the bill — titled “To amend title XVIII of the Social Security Act to establish requirements with respect to the use of prior authorization under Medicare Advantage plans, and for other purposes” — is not yet publicly available, and there is no summary posted on the Congress.gov website.

According to the ACR, the bill would, among other provisions, establish a process so that “real-time decisions” can be made regarding services that are routinely approved. In addition, the legislation would require Medicare Advantage plans to offer an electronic prior authorization process, and to report to CMS the extent of their use of prior authorization, as well as how often they approve or deny medications and services, the group said.

In a press release, the ACR praised the bill, stating it would protect patients from prior authorization requirements that “needlessly delay or deny access to medically necessary care.”

“While originally intended to control costs by reducing unnecessary tests and procedures, many health plans are now indiscriminately using prior authorization, creating additional hurdles for patients and physicians that can lead to delays in treatment that may endanger patients’ health,” ACR wrote in the release. “The process for obtaining this approval can be lengthy and typically requires a physician or their staff to spend many hours each week negotiating with insurance companies — time that could be better spent taking care of patients.”

The ACR is supporting the legislation as part of the Regulatory Relief Coalition, a group of national physician specialty organizations that advocate against what they describe as regulatory burdens within Medicare, with the stated goal of protecting patients’ access to timely care.

The Regulatory Relief Coalition recently released a national survey of 1,602 physicians, in which 87% of respondents reported that prior authorization has had a “significant” or “somewhat negative” impact on their patients’ clinical outcomes.

“Nearly a third of physicians surveyed said their patients often abandon treatment due to prior authorization,” ACR wrote in the release. “Furthermore, 84% of survey respondents said that the regulatory burdens associated with prior authorization has significantly increased over the past five years, with half of all practices reporting 11 or more requests per week.”

Paula Marchetta

The American College of Rheumatology has applauded a proposed federal bill that would amend the Social Security Act to regulate the use of prior authorization for patients with Medicare Advantage plans.

The bill, H.R. 3107, was introduced in the U.S. House of Representatives, and referred to the Ways and Means Committee and Committee on Energy and Commerce on June 5. It is sponsored by Rep. Suzan DelBene, D-Wash., and cosponsored by representatives Mike Kelly, R-Pa., Roger Marshall, R-Kan., and Ami Bera, D-Calif.

“For far too long, patients have faced unnecessary and unreasonable care delays due to insurers’ overzealous use of prior authorization,” Paula Marchetta, MD, MBA, president of the ACR, said in a press release. “This practice creates significant burdens for physicians and can put patient’s health in jeopardy. We applaud Congressional leaders for standing up to ensure America’s Medicare beneficiaries are able to get the care they need and deserve.”

 
The bill would amend the Social Security Act to regulate the use of prior authorization for patients with Medicare Advantage plans, according to the ACR.
Source: Shutterstock

The text of the bill — titled “To amend title XVIII of the Social Security Act to establish requirements with respect to the use of prior authorization under Medicare Advantage plans, and for other purposes” — is not yet publicly available, and there is no summary posted on the Congress.gov website.

According to the ACR, the bill would, among other provisions, establish a process so that “real-time decisions” can be made regarding services that are routinely approved. In addition, the legislation would require Medicare Advantage plans to offer an electronic prior authorization process, and to report to CMS the extent of their use of prior authorization, as well as how often they approve or deny medications and services, the group said.

In a press release, the ACR praised the bill, stating it would protect patients from prior authorization requirements that “needlessly delay or deny access to medically necessary care.”

“While originally intended to control costs by reducing unnecessary tests and procedures, many health plans are now indiscriminately using prior authorization, creating additional hurdles for patients and physicians that can lead to delays in treatment that may endanger patients’ health,” ACR wrote in the release. “The process for obtaining this approval can be lengthy and typically requires a physician or their staff to spend many hours each week negotiating with insurance companies — time that could be better spent taking care of patients.”

The ACR is supporting the legislation as part of the Regulatory Relief Coalition, a group of national physician specialty organizations that advocate against what they describe as regulatory burdens within Medicare, with the stated goal of protecting patients’ access to timely care.

The Regulatory Relief Coalition recently released a national survey of 1,602 physicians, in which 87% of respondents reported that prior authorization has had a “significant” or “somewhat negative” impact on their patients’ clinical outcomes.

“Nearly a third of physicians surveyed said their patients often abandon treatment due to prior authorization,” ACR wrote in the release. “Furthermore, 84% of survey respondents said that the regulatory burdens associated with prior authorization has significantly increased over the past five years, with half of all practices reporting 11 or more requests per week.”

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