On June 12, 2024, Senator Roger Marshall reintroduced his bipartisan, bicameral Improving Seniors’ Timely Access to Care Act. The legislation is also sponsored by U.S. Senators Kyrsten Sinema (I-AZ), John Thune (R-SD), and Sherrod Brown (D-OH), and U.S. Representatives Mike Kelly (R-PA), Suzan DelBene (D-WA), Larry Bucshon, M.D. (R-IN) and Ami Bera, M.D. (D-CA). An additional 37 senators and 123 representatives also cosponsor the legislation, which has support from more than 370 national and state organizations that represent patients, physicians, Medicare Advantage (MA) plans, hospitals, and other stakeholders in the health care industry.
Under the legislation, an electronic prior authorization process would be established for MA plans, including a standardization for transactions and clinic attachments. It would also increase transparency around MA prior authorization requirements and clarify the authority that CMS has to establish timeframes for electronic prior authorization requests (including expedited determinations, real-time decisions for routinely approved items and services, and other prior authorization requests). The legislation would also require the Department of Health and Human Services (HHS) and other government agencies to report to Congress on program integrity efforts and other ways to further improve the electronic prior authorization process.
According to Senator Marshall’s office, the last time he introduced this legislation, it was stalled in the Senate – after passing in the House – due to concerns over its cost. This time, Senator Marshall and the co-leads made a major change to reduce the Congressional Budget Office’s (CBO’s) score of the legislation to zero. The leading sponsors met with CBO staff and Congressional Committees of jurisdiction to reduce the score by calling on the Centers for Medicare and Medicaid Services (CMS) to implement the bill through the rulemaking process. CMS did so in December 2022 through three proposed rules. CMS’ Office of the Actuary estimated that the total burden across all providers would be reduced by at least 220 million hours over a decade, resulting in at least $16 billion in cost savings.
A majority of Senators and Representatives sent a letter to CMS in June 2023, urging the finalization of the electronic prior authorization rules. Once CMS issued the final rule, the leading sponsors made adjustments to the proposed legislation to address changes made by CMS in the rule. While the final rules from CMS significantly reduced the cost of legislation, it did not eliminate it due to real-time decision requirement and expedited determinations. This version of the legislation replaced those requirements with cost-neutral alternatives, including a public report on establishing real-time decisions and clarifying CMS’ authority to establish expedited determinations and other timeline requirements.
“Prior authorization is the number one administrative burden facing physicians today across all specialties, Senator Marshall said. “As a physician, I understand the frustration this arbitrary process is causing health care practices across the country and the headaches it creates for our nurses. With the bipartisan, bicameral, Improving Seniors’ Timely Access to Care Act, we will streamline prior authorization and help improve patient outcomes and access to quality care and life-saving medicine. With the improvements we’ve made there is no reason we should not quickly get this bill signed into law.”
“Modernizing and streamlining the prior authorization process is critical for South Dakota seniors and providers,” said Senator John Thune (R-SD). “This bipartisan legislation would remove unnecessary red tape, make health care more efficient, and ensure patients can access care when they need it.”
“Right now, too many older Americans enrolled in Medicare Advantage are forced to deal with unnecessary delays when seeking out medical treatment,” said Senator Sherrod Brown (D-OH). “We need to update the Medicare Advantage program so it works better, faster, and is more transparent for patients and providers. By requiring private insurance companies to streamline prior authorization processes electronically, we can ensure providers can quickly access the information they need to treat and care for their patients in a timely manner.”
“We’ve made important incremental headway in helping seniors get the medical care they deserve with the administration’s prior authorization regulations. However, we must go further and enshrine these advancements into law. By passing the bipartisan, bicameral Improving Seniors’ Timely Access to Care Act, we can make it much easier for seniors to receive the care they’re entitled to while also alleviating unnecessary burdens on physicians and hospitals,” said Congresswoman Suzan DelBene (D-WA).
Support for the Legislation
The American Hospital Association (AHA) supports the legislation, saying that the electronic prior authorization standard established by the legislation would “streamline approvals, reduce the amount of time a health plan is allowed to consider a prior authorization request, 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.”
“This is a pivotal moment for enhancing patients’ access to care,” said Russell R. Lonser, MD, FAANS, chair of the department of neurosurgery at The Ohio State University and chair of the American Association of Neurological Surgeons and Congress of Neurological Surgeons Washington Committee. He added, “The widespread overuse of prior authorization, especially in Medicare Advantage, has led to unacceptable delays and denials of essential medical treatments. We are optimistic that this will be the year Congress acts to safeguard timely care for our seniors.”
George A. Williams, MD, senior secretary for advocacy of the American Academy of Ophthalmology, said, “The swift passage of the Improving Seniors’ Timely Access to Care Act is an important action for Medicare beneficiaries and much-needed step for reducing unwarranted administrative burdens on the physicians and care for them.” Dr. Williams noted, “Seniors who enroll in Medicare Advantage plans deserve the same access to Medicare-covered items and services as beneficiaries who opt for Medicare fee-for-service. Congress should act quickly to make it a reality.”