Lawmakers take aim at Medicare Advantage prior authorization

A group of U.S. lawmakers have introduced legislation aimed at reforming the Medicare Advantage prior authorization process. 

The legislation is an updated version of the Improving Seniors’ Timely Access to Care Act, which passed the House of Representatives in 2022, but stalled in the Senate, according to a June 12 news release from Washington Rep. Susan DelBene's office. 

"Prior authorization is the number one administrative burden facing physicians today across all specialties," Kansas Sen. Roger Marshall, MD, said in a June 12 news release from his office. "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." 

If passed, 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 the HHS' authority to establish timeframes for electronic 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 electronic prior authorization process. 

In January, CMS finalized a rule to streamline the prior authorization process. The proposed legislation would codify many of those provisions to "ensure no future administration could undo them and make further improvements," according to the release from Ms. DelBene's office. 

The bill is sponsored by 130 members of the House of Representatives and 42 Senators, according to the release.

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