For too long and for too many patients, the process of obtaining prior authorization for a medical procedure or medicine has been a tangled web, as people are forced to navigate complex, confusing and burdensome regulations from some commercial insurers that have resulted in the delay or denial of needed care.

Slightly more than half of America’s eligible Medicare population — more than 33 million people — are enrolled in Medicare Advantage (MA) plans, and they are more likely than those in traditional Medicare to report delays in care due to needed insurance approvals. The misuse or misapplication of prior authorization requirements has led to dangerous delays in treatment, clinician burnout and waste in the health care system.

The process has been crying out for reform. Patients and their care providers have a right to expect from insurers care and payment decisions that are timely, straightforward and that put quality medical care first.

Addressing abuses of prior authorization has been a top AHA priority. We have been working on many fronts to push back against these practices, as well as other MA plan abuses, and have repeatedly urged the Centers for Medicare & Medicaid Services to address these important issues. We also are coordinating closely with the allied state hospital associations to advance similar efforts on all commercial insurers, not just those serving MA enrollees.

CMS listened and acted. Earlier this year, the agency issued a final rule  requiring MA, Medicaid, Children's Health Insurance Program and federally facilitated Marketplace plans to streamline their prior authorization processes to improve timely access to care for patients and alleviate provider administrative burden.

At the same time, the AHA also is working with leaders on Capitol Hill to expand and reinforce some of the advancements realized through the CMS work. This month, we were pleased to support the reintroduction of the Improving Seniors’ Timely Access to Care Act, bipartisan and bicameral legislation that would streamline prior authorization requirements under MA plans.

Among other badly needed improvements, the bill would: establish an electronic prior authorization standard to 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.

These are all promising steps forward. By removing unnecessary barriers that create delays in treatment, this meaningful bill will improve access to care for seniors and allow caregivers to spend more valuable time at the bedside with patients and less time on burdensome paperwork.

The AHA greatly appreciates the leadership from this bipartisan group of senators and representatives to streamline the broken prior authorization process in the MA program. But it is not a done deal. 

The Improving Seniors’ Timely Access to Care Act is one of many pieces of legislation that could be considered as part of a post-election lame-duck session at the end of the year.

We’re going to keep advocating for it, and we need your help. We urge hospital and health system leaders to talk with their lawmakers about why this legislation is so important for patients and providers, and why we must enact it soon. 

In the end, making sure that MA plans provide the needed coverage that patients expect and pay for is about honoring a deal made in good faith, a deal that has sometimes strayed off the rails in recent years.

We will continue to work with CMS, Congress and others to make sure all Medicare beneficiaries can access the care they need.

Related News Articles

AdventHealth’s Be a Mindleader initiative aims to help children and parents become more comfortable discussing mental health and connect families to counseling…
Access to quality mental and physical health services can be a complex challenge, but for individuals of color and people with severe or chronic mental…
The Centers for Medicare & Medicaid Services July 16 released its final guidance on the Medicare Prescription Payment Plan which will begin next year. The…
EnglISH¿Qué pasa si una conversación puede cambiar, o incluso salvar, una vida? Esa fue la pregunta que AdventHealth buscó responder, cuando el sistema de…
ESPAÑOLWhat if one conversation can change, or even save, a life? That was the question AdventHealth sought to answer, as the health system launched a…
The AHA July 11 released its quarterly Health Care Plan Accountability Update, a roundup of news, letters, statements and other resources covering private…