Reps. Susan DelBene, D-WA, Mike Kelly, R-PA, Ami Bera, D-CA, and Roger Marshall, R-KS, introduced the Improving Seniors Timely Access to Care Act of 2019, HR 3107, legislation that would streamline the prior authorization process in the Medicare Advantage program to relieve the administrative burdens this poses for physicians and help patients receive quicker access to the medical care they need.
One in every three people with Medicare is enrolled in a Medicare Advantage (MA) plan. Under current law, MA plans may not create inappropriate barriers to care that do not already exist within the original Medicare program. However, physicians are reporting that MA plans have imposed increasingly onerous prior authorization requirements for medical services and procedures that are impacting patient access to medically necessary care. AGA and other physician organizations have been advocating for changes related to how MA plans use prior authorization. The Improving Seniors Timely Access to Care Act of 2019 is the culmination of work that AGA and the physician community have been recommending that CMS and Congress require the MA plans to implement.
“Prior authorization impacts health care providers’ ability to provide timely care to our patients; this not only delays access to vital treatments, but can put our patients’ lives at risk,” said Hashem B. El-Serag, MD, MPH, AGAF, president, AGA Institute. “This issue is a top priority for the American Gastroenterological Association (AGA), and we support the Improving Seniors Timely Access to Care Act of 2019, which provides simplification and efficiency in the prior authorization process, allowing health care providers to spend more time caring for their patients.”
The legislation would reduce the administrative burdens of prior authorization in the MA program by requiring the plans to do the following:
- Establishes an electronic prior authorization process. Facsimiles are not considered electronic prior authorization transmissions.
- MA plans may not require prior authorization on any surgical or other invasive procedure if this procedure is furnished during the peroperative period.
- The Secretary of HHS will establish a process for “real-time decisions” for routine non-complex items and services for which prior authorization requests are routinely approved.
- MA plans must meet certain transparency requirements including:
- Must submit to the Secretary at least annually (1) a list of all items and services that are subject to PA; (2) the percentage of prior authorization requests approved during the previous plan year; and (3) the average amount of time elapsed between the PA request and the final determination.
- Plan must publish this information on a public website.
- The Secretary must provide an annual report to Congress.
- The Secretary will issue the following guidance to MA plans:
- MA plans should adopt transparent prior authorization programs, developed in consultation with physicians, that adhere to evidence-based medical guidelines
- MA plans should conduct annual reviews of items and services for which prior authorization is imposed, reflecting the input of physicians, an analysis of past prior authorization requests and current clinical criteria.
- MA plans should ensure continuity of care for individuals transitioning between coverage to minimize any disruption related to prior authorization.
- MA plans should make timely prior authorization determinations, provide rationales for denials and ensure requests are reviewed by qualified medical personnel.
Because prior authorization impacts our ability to provide timely care to patients, AGA urges you to contact your legislator and encourage them to support the Improving Seniors Timely Access to Care Act of 2019. It will take less than five minutes to help us advance this bill and help provide a simpler process that’s less burdensome on our practices.