In mid-May 2022, H.R. 3173, the Improving Seniors’ Timely Access to Care Act of 2021 surpassed the 290-cosponsor threshold needed to include the legislation on the House Consensus Calendar. If passed, the bipartisan bill would streamline and standardize prior authorization in the Medicare Advantage (MA) program.
Under the legislation, MA plans would need to: (1) establish an electronic prior authorization program that meets specified standards, including the ability to provide real-time decisions in response to requests for items and services that are routinely approved; (2) annually publish specified prior authorization information, including the percentage of requests approved and the average response time; and (3) meet other standards, as set by the Centers for Medicare & Medicaid Services (CMS), relating to the quality and timeliness of prior authorization determinations.
HHS OIG MA Report
The 290-cosponsor threshold was met just weeks after the Department of Health and Human Services Office of Inspector General (HHS OIG) released a report, Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care. After finishing the study, HHS OIG found that Medicare Advantage Organizations (MAOs) sometimes delayed or outright denied MA beneficiaries’ access to services, despite the request meeting Medicare coverage rules. MAOs also occasionally denied payments to providers for services that met both Medicare coverage rules and MAO billing rules.
More specifically, HHS OIG found that among prior authorization requests that MAOs denied, 13% met Medicare coverage rules and likely would have been approved for beneficiaries under Medicare fee-for-service. HHS OIG also found that MAOs indicated some prior authorization requests did not have enough documentation to support approval, but the reviewers found that the medical records were actually sufficient to support the medical necessity of the services.
When it comes to denied payment requests, 18% of the payment requests denied by MAOs met Medicare coverage rules and MAO billing rules. Most of those payment denials were caused by human error during manual claims processing reviews and system processing errors.
Supportive Comments
The American Academy of Ophthalmology (AAO) supports the legislation and has urged Congress to pass the bipartisan bill. “The overwhelming and bipartisan support for the Improving Seniors’ Timely Access to Care Act is evidence that the relief we are fighting for is vital and urgent for our patients and our profession,” said Stephen D. McLeod, MD, CEO of the American Academy of Ophthalmology. “We’re pleased that Congress recognizes the importance of addressing egregious prior authorization policies and we hope lawmakers take swift action to pass this common-sense legislation.”