The American Medical Association (AMA) and a bipartisan group of Congressional leaders are looking to stop unfair prior authorization practices from health plans.
Introduced by Rep. Suzan DelBene (D-Washington), the Improving Seniors’ Timely Access to Care Act (PDF) is intended to modernize prior authorization in Medicare Advantage (MA). It is sponsored by 130 members from the House and 42 Senators.
“We’ve made important incremental headway in helping seniors get the medical care they deserve with the administration’s prior authorization regulations,” said DelBene in a statement. “However, we must go further and enshrine these advancements into law.”
She said prior authorization burdens physicians and patients with long delays and unfair denials.
The bill, which unanimously passed the House in September 2022, would standardize the prior auth process for MA plans, mandate improved transparency and codify deadlines on prior auth decisions.
The new legislation obtained approval from the AMA and other industry groups such as Premier, MGMA, the Better Medicare Alliance and the American Academy of Family Physicians (AAFP). More than 370 organizations support the legislation, a list shared by DelBene shows.
“Modernizing prior authorization for Medicare Advantage patients is vital to reducing the delayed care, harm and costs, which are the legacy of an antiquated process requiring faxes and phone calls in time-sensitive clinical situations,” said Soumi Saha, senior vice president of government affairs for Premier, in a statement.
"The average physician spends two business days completing prior authorizations," explained AAFP President Steven Furr, M.D. "The impacts on patient care are jarring, with nearly 97% of physicians reporting that their patients experienced delays or denials for medically necessary care due to prior authorization requirements."
“We think this is the year to get this bill over the finish line,” said AMA President Bruce Scott, M.D.
Insurers, however, say prior auth policies are important tools in reducing costs and ensuring care is both medically necessary and safe, but plans increasingly face backlash for restrictive requirements.
Some payers support the proposal, including Humana.
"We are encouraged that the bill promotes expediting approvals of care through greater adoption of electronic prior authorization, which has been demonstrated to improve health outcomes and reduce costs for patients," said Humana Chief Medical Officer Kate Goodrich, M.D., in a statement shared with Fierce Healthcare.
During AMA’s annual meeting Tuesday, representatives agreed health insurers should be legally accountable when prior auth policies conflict with the best interests of patients.
“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” said AMA Board Member Marilyn Heine, M.D, in a statement. “To protect patient-centered care, the AMA will work to support legal consequences for insurers that harm patients by imposing obstacles and burdens that interfere with medically necessary care.”
AMA also wants to see better justification as to why claims are denied from insurers in the form of a denial letter that includes reasoning, rules or policies cited, what it would take to approve treatment and possible alternative treatments.
Real-time prescription benefit tools, which streamlines decisions or offer treatments that do not need prior auth by letting physicians access drug coverage information in electronic health records, is another priority for the organization.
Other resolutions at the annual meeting called for Medigap annual open enrollment periods and expanded hearing and vision coverage for Medicaid members.