House passes prior authorization reform bill: 4 things to know

The U.S. House of Representatives unanimously passed a bill Sept. 14 to reform the Medicare Advantage prior authorization process. 

Four things to know: 

1. Among other things, the bill would establish an electronic prior authorization process and require Medicare Advantage plans to report to CMS the extent of their use of prior authorization and the rate of approvals or denials. It would also require HHS to develop a process for "real-time decisions" on items and services that are routinely approved. 

2. The bill now goes to the Senate for further consideration. Washington Rep. Suzan DelBene, one of the bill's primary sponsors, said in a news release the bill "also has strong bipartisan support" in that chamber. 

3. The bill was originally introduced in 2021. Its sponsors gained traction on the legislation this spring after an HHS Office of the Inspector General's report found that 13 percent of Medicare Advantage prior authorization request denials would have been approved for beneficiaries under original Medicare coverage rules. The report also found 18 percent of denied payment requests met Medicare coverage rules and Medicare Advantage Organization billing rules.

4. Groups supporting the legislation include the American Hospital Association, Medicare Advantage advocacy group Better Medicare Alliance, the American Academy of Ophthalmology and the Medical Group Management Association, which are calling on the Senate to take quick action on the bill. 

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