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HAP and National Health Care Coalition Urge Congress to Reform Prior Authorization

May 17, 2021

HAP and a coalition of more than 70 leading health care organizations are calling on Congress to pass legislation that would protect Medicare Advantage patients from unnecessary delays in care and modernize the prior authorization process.

Last week, lawmakers in the House of Representatives introduced the Improving Seniors’ Timely Access to Care Act of 2021. The bipartisan legislation, championed by Congressman Mike Kelly (R, PA-16), would streamline and standardize the way Medicare Advantage plans use prior authorization, adding oversight and transparency into that process, federal lawmakers said.

“Americans who are enrolled in Medicare Advantage plans sometimes face unnecessary delays in treatment and diagnoses, but this legislation will modernize the process of prior authorization so medical providers can offer them safe, timely, and affordable care,” Kelly said in a statement. “This common sense, bipartisan plan will give seniors peace of mind and improve America’s health care system.”

Improving the prior authorization process is a top health care priority throughout the U.S. Prior authorization requires patients to get pre-approval from their health insurer before they have certain non-emergent medical tests, are admitted to the hospital, or receive prescription drugs or medical equipment.

During 2018, the U.S. Department of Health & Human Services’ (HHS) Office of the Inspector General revealed that Medicare Advantage plans ultimately approved 75 percent of requests that were originally denied, representing about 216,000 overturned denials each year.

This legislation would:

  • Establish an electronic prior authorization process
  • Require HHS to establish a process for “real-time decisions” for items and services that are routinely approved
  • Improve transparency by requiring Medicare plans to report to the Centers for Medicare & Medicaid Services (CMS) about their use of prior authorization and the rate of approvals or denials
  • Encourage plans to adopt prior authorization programs that follow evidence-based medical guidelines in consultation with physicians

A previous version of this bipartisan legislation was introduced during 2019 and was cosponsored by 280 members, including all 18 members of the Pennsylvania U.S. House Delegation.

HAP continues to advocate for state and federal policies that streamline the prior authorization process and ensure patients have timely access to the care they need to live healthy lives.

Earlier this year, CMS published its final rule on prior authorization and interoperability, requiring  payors with plans in Medicaid, the Children’s Health Insurance Program, and the federal marketplace to create digital platforms that give providers and patients access to prior authorization data. The new CMS rule, effective January 1, 2024, also will shorten the timeline for payors to review requests for urgent and non-urgent care.

For more information about this prior authorization legislation, please contact Jolene Calla, Esq., HAP’s vice president, health care finance and insurance; or to discuss the federal advocacy strategy on this initiative, contact Laura Stevens Kent, HAP’s senior vice president, strategic integration.