HAP Endorses Federal Effort to Protect Patients from Delays in Care, Lauds Rep. Mike Kelly’s Efforts to Standardize Prior Authorization
August 22, 2019
HAP has joined more than 300 patient, physician, health care professional, and other health care stakeholder organizations in expressing support for bipartisan legislation that would help protect patients from unnecessary delays in care.
HAP applauds U.S. Representative Mike Kelly’s (R, PA-16) efforts, as an original author of the legislation, to ensure Medicare Advantage beneficiaries—more than one million older people and individuals with disabilities in Pennsylvania—do not face unnecessary red tape in getting the health care they need when they need it.
The newly introduced legislation—Improving Seniors’ Timely Access to Care Act (H.R. 3107)— would streamline and standardize prior authorization under the Medicare Advantage program.
Prior authorization is the insurance practice of requiring a health care provider to obtain advance approval from a health plan before a specific procedure, service, device, supply, or medication can be delivered to a patient and qualify for payment by that plan.
Other terms used by health plans for this process include “preauthorization,” “precertification,” “prior approval,” “prior notification,” “prospective review,” and “prior review.”
The federal legislation would:
- Create an electronic prior authorization program
- Increase oversight on how Medicare Advantage plans use prior authorization
- Require plans to adopt transparent prior authorization programs that are reviewed annually, and hold plans accountable for making timely prior authorization determinations and to provide rationales for denials
Representative Kelly introduced the bill in collaboration with Representatives Suzan DelBene (D-WA), Roger Marshall, MD (R-KS), and Ami Bera, MD (D-CA). Dr. John Joyce (R, PA-13) also has signed on as a co-sponsor of the legislation.
Strong support from health care stakeholders and bipartisan interest in Congress signals the possibility that reforms may be implemented. More than 100 Members of Congress called for prior authorization reforms within the Medicare Advantage program in a letter last year to Centers for Medicare & Medicaid Services Administrator Seema Verma.
This federal initiative runs parallel to work at the state level to address prior authorization.
HAP has supported state legislation—House Bill 1194, sponsored by Representative Steven Mentzer (R-Lancaster)—that would protect patients from care delays by:
- Placing commonsense requirements on insurers to make timely decisions and pay claims for medically necessary care that could not be pre-authorized (such as a necessary service that was identified during the course of an authorized treatment)
- Publishing data about prior authorization approvals and denials on an annual basis
HAP President and CEO Andy Carter recently highlighted the support of a coalition of 33 health care organizations that represent Pennsylvania providers (hospitals and 17 different kinds of doctors) as well as patients (people with cancer and 14 other kinds of diseases) for commonsense reforms.
See HAP’s factsheet, Reforming Prior Authorization; Protect Patient Access to Timely Care, for information about increasing prior authorization delays and denials and the impact on quality.
HAP will continue to advocate both at the state and federal level to reform the prior authorization process in an effort to improve access to timely care for Pennsylvania patients.
For more information, please contact Kate Slatt, HAP’s senior director, innovative payment and care delivery, Laura Stevens Kent, HAP’s vice president, federal legislative advocacy, or Stephanie Watkins, HAP’s vice president, state legislative advocacy.