Senate Introduces Bipartisan Prior Authorization Legislation: Timely Access to Care Act

On October 20, 2021, a group of bipartisan United States Senators (Roger Marshall, MD (R-KS); Krysten Sinema (D-AZ); and John Thune (R-SD)) introduced S. 3018, the Improving Seniors’ Timely Access to Care Act. The legislation attempts to improve timely access to quality care for seniors on Medicare Advantage by modernizing the way MA plans and health care providers use prior authorization.

Prior authorization has been called the “#1 administrative burden” by health care providers, with nearly 80% of Medicare Advantage enrollees subject to unnecessary delays as a result. The Office of the Inspector General at the United States Department of Health and Human Services (HHS OIG) raised concerns after an audit revealed that MA plans wound up approving 75% of requests that were initially denied as a result of prior authorization.

The legislation would establish an electronic prior authorization process to streamline approvals and denials; establish national standards for clinical documents that would reduce administrative burdens; create a process for real-time decisions for certain items and services that are routinely approved; increase transparency to improve communication channels and utilization between MA plans, health care providers, and patients; and require beneficiary protections to serve seniors first.

The bipartisan House of Representatives companion bill was reintroduced in May 2021.

“Having served as a physician in rural Kansas for decades, my top priority has always been to provide quality care to my patients,” said Senator Marshall. “This legislation cuts the red tape hindering health care providers across the nation from providing our seniors with quality care in a timely manner. The common-sense solutions we are offering were formed in partnership with hundreds of national and state organizations over the last two years, and I am honored to lead this bipartisan, bicameral effort alongside Senators Sinema and Thune.”

Many Groups Express their Support for the Legislation

“Physicians know the best treatment for our patients but they’re often not the ones making the final decision due to artificial barriers constructed by insurance companies,” said American Medical Association (AMA) President Gerald E. Harmon, MD. “The time delays and administrative burdens associated with prior authorization continue to undermine our patients’ health. Nearly a third of physician respondents to a 2020 AMA survey reported that prior authorization led to a serious adverse event — such as hospitalization, medical intervention to prevent permanent impairment, or even disability or death — for a patient in their care. The AMA thanks Senators Marshall, Sinema, and Thune for putting patients first by introducing the Improving Seniors’ Timely Access to Care Act, which would simplify and streamline the prior authorization processes in Medicare Advantage.”

The American Society for Radiation Oncology (ASTRO) expressed its support for the legislation, saying that “unnecessarily obstructive prior authorization practices can lead to potentially life-threatening delays in cancer treatment, and these delays increased during the COVID-19 public health emergency. Prior authorization is not achieving its intended goal of improving efficiency and quality in American health care.”

The Medical Group Management Association (MGMA) also expressed support for the legislation, noting that “removing dangerous barriers to the timely delivery of necessary patient care…would simplify administrative processes and remove onerous prior authorization requirements for medical practices, allowing physicians to focus on their primary goal of treating patients.”

The American Hospital Association also supports the legislation, saying that the prior authorization varies “widely among health plans and insurers, and the lack of standardization can be confusing and burdensome for providers. Unfortunately, certain health plan utilization management practices can, when poorly structured or implemented, create unnecessary delays in care that can negatively affect patients.”