On September 14, 2022, the Improving Seniors’ Timely Access to Care Act of 2022 passed the United States House of Representatives. The legislation as currently drafted establishes several requirements and standards relating to the prior authorization processes under Medicare Advantage (MA) plans.
Specifically, the legislation states that MA plans must do the following:
- 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;
- Annually publish specified prior authorization information, including the percentage of requests that are approved and the average response time; and
- Meet other standards as set by the Centers for Medicare and Medicaid Services (CMS), relating to the quality and timeliness of prior authorization determinations.
The legislation specifically notes that when it comes to the definition of an “electronic transmission,” a facsimile, a proprietary payer portal that does not meet standards specified by the Secretary, or an electronic form shall not be treated as an electronic transmission.”
The legislation also directs the Secretary of Health and Human Services (HHS) to use notice and comment rulemaking to establish and update the definition of a “real-time decision” as well as to initially identify and update applicable items for which prior authorization requests are routinely approved.
Additionally, Medicare Advantage plans will need to submit annual reports (in a manner to be specified by the HHS Secretary). The annual reports will include a variety of information, including a list of all applicable items and services that were subject to a prior authorization requirement under the plan during the prior plan year, and the percentage (and number) of specified requests that were approved during the previous plan year by the plan in an initial determination and the percentage (and number) of specified requests that were denied by the plan in an initial determination.
Industry Comments
Anders Gilberg, the Senior Vice President of Government Affairs for the Medical Group management Association (MGMA) released a statement saying, “This legislation would lessen administrative burden for medical groups by moving the prior authorization process into the 21st century. The transparency provisions included in this legislation — requiring MA plans to publicly reveal what services are subject to prior authorization, how many are approved, and how long on average they take to approve — will drive plan accountability.” Gilberg went on to note that, “by streamlining and standardizing the overly cumbersome and wildly inefficient MA prior authorization process, this legislation will return a focus to the physician-patient relationship and prevent dangerous delays to timely care. MGMA urges the Senate to move swiftly to consider this bill, helping to ensure our nation’s seniors have unobstructed access to the high-quality healthcare they deserve.”
Stacey Hughes, the Executive Vice President at the American Hospital Association (AHA) also supports the legislation, writing a letter to Congressman Richard Neal and Congressman Kevin Brady, urging the passage of the legislation. In her letter, Hughes notes that the legislation “would address many of [the] concerns [raised by AHA regarding prior authorization] by establishing requirements for the use of prior authorization under MA plans. Specifically, this bill would establish an electronic prior authorization process to streamline approvals, reduce the amount of time a health plan is allowed to consider a prior authorization request, create a process for “real-time decisions” for services that are routinely approved, require MA plans to report on their use of prior authorization and the rate of approvals and denials, and encourage MA plans to adopt policies that adhere to evidence-based guidelines.”
The American Medical Association also supports the legislation, saying, “The additional sections of the legislation mandating MA plans to issue faster prior authorization decisions are crucial policy improvements that will ensure more timely access to care and, as a result, improved patient health care outcomes and better stewardship of scarce Medicare resources…The AMA is proud to support the Improving Seniors’ Timely Access to Care Act. We commend the Ways and Means Committee for marking up this crucial bill and stand ready to work to ensure bipartisan passage by the House of Representatives.”