In a somewhat rare bipartisan (and bicameral) moment, legislators from both chambers of Congress are urging the Biden Administration to finalize updates to prior authorization – updates that were proposed back in December 2022. Under the proposal the Centers for Medicare and Medicaid Services (CMS) proposed requiring government payers to switch to an electronic prior authorization process by 2026.
The letter from the Senators recognizes that the proposal “attempt[s] to stroke a balance between the program integrity and patient access to care,” and that prior authorization, “when used appropriately, is an important tool to manage costs and ensure program integrity.”
The Senators also asked CMS to even expand upon the proposal by establishing a mechanism for real-time electronic prior authorization decisions for routinely approved items and services; requiring that plans respond to prior authorization requests within 24 hours for urgently needed care; and requiring detailed transparency metrics. The Senators raise concerns that delaying care by up to 72 hours instead of 24 “could jeopardize a patient’s life, health, or ability to regain maximum function.”
To that end, the letter mentions the Improving Seniors’ Timely Access to Care Act (S. 3018/H.R. 3173), which would (together with the CMS proposal): establish an electronic prior authorization process for Medicare Advantage (MA) plans; accelerate prior authorization decision time frames; reduce the administrative burden for providers and health plans; increase transparency around prior authorization requirements and clinical information needed to support decisions; and expand beneficiary protections to improve patient experiences and outcomes. The legislation has passed the House.
In total, sixty-one senators signed the letter.
The letter from the House of Representatives largely mirrors the letter from the Senate, again discussing the Improving Seniors’ Timely Access to Care Act and the changes the chamber would like for CMS to implement to better the prior authorization process, including changing the timeframe for expedited requests from 72 hours to 24 hours. 233 representatives signed the letter from the House.
It’s Not Just Congress
It’s not just the chambers of Congress asking for changes and updates to the prior authorization program, but also physicians and physician groups. For example, Russell R. Lonser, MD, FAANS, chair of the department of neurosurgery at Ohio State University and chair of the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Washington Committee, released a statement saying, “Our message to policymakers is simple: our patients cannot afford to wait or jump through unnecessary hoops to get care for painful, debilitating and life-threatening neurologic conditions. When finalized, these rules would remove barriers to patients’ timely access to care and allow physicians to spend more time treating patients and less time on paperwork.”