Physician Coalition Lauds Proposed Rule Mirroring House-Passed Bill to Streamline Prior Authorization in Medicare Advantage Program
Prior Authorization in Medicare Advantage Program
RRC Concurs with CMS that Changes are “overdue, feasible, and would benefit patients and providers.”
WASHINGTON, DC—The Regulatory Relief Coalition (RRC) — a group of national physician specialty organizations advocating for reduced regulatory burdens that interfere with patient care — enthusiastically lauds the Centers for Medicare & Medicaid Services (CMS) for its recently released proposed rule.
The proposed rule’s provisions regarding Medicare Advantage (MA) plans closely align with the Improving Seniors’ Timely Access to Care Act (S. 3018/S.R. 3173), legislation initiated by the RRC that unanimously passed the House by voice vote in September. If adopted, the proposed rule and the legislation would both require MA plans to address prior authorization requests more promptly — streamlining and simplifying the process to ensure the timely provision of patient care.
The proposal shares many elements of the legislation for improving prior authorization. Most notably, the rule and the bill both:
• Seek to reduce care delays and improve patient outcomes;
• Aim to advance interoperability and improve prior authorization processes by requiring MA plans to adopt electronic prior authorization (E-PA);
• Ensure MA plans respond to prior authorization requests within specific timeframes;
• Require public reporting on the use of prior authorization with specific and detailed transparency on MA prior authorization;
• Support efforts to waive or modify prior authorization requirements based on provider performance; and
• Acknowledge that health plans’ proprietary interfaces and web portals through which providers submit their requests remain inefficient and burdensome.
Furthermore, the proposal and the bill also closely align with the stated rationale for improving prior authorization processes. Both the rule and the bill acknowledge that prior authorization:
• Plays an important role in utilization management, but it can be misused or overused, creating considerable challenges for patients, providers, and payers;
• Presents a serious health risk for patients when care is delayed;
• Increases provider and payer burden due to inconsistent payer policies, provider workflow challenges, and unpredictable use of electronic standards; and
• Contributes to significant provider burnout.
“Patients and physicians are thrilled that the proposed rule paves the way for commonsense,
necessary, and appropriate changes to prior authorization in Medicare Advantage and other
government health programs. Congress should take action before the end of this year and codify
these vital principles by passing the Improving Seniors’ Timely Access to Care Act,” said John K.
Ratliff, MD, FAANS, a practicing neurosurgeon at Stanford University, and chair of the American
Association of Neurological Surgeons/Congress of Neurological Surgeons Washington Committee.
George A. Williams, MD, Senior Secretary for Advocacy of the American Academy of Ophthalmology
said, “We strongly support the agency’s recognition that this rule could prevent patients from
abandoning care while waiting for an authorization, improve efficiencies for providers who must
check on the status of an authorization over the course of several days or sometimes weeks.” He
added, “the rule, codified by the bill’s passage, will allow for real-time decisions, full transparency,
and real patient protections for America’s seniors. Our patients can’t wait any longer for relief.”
The bipartisan bill was propelled by more than 375 combined House and Senate co-sponsors and over
500 endorsing organizations representing patients, health care providers, medical technology and
biopharmaceutical industry, health plans, and others seeking to ensure that bureaucratic hurdles do
not stand in the way of physicians providing medically necessary patient care.
The coalition especially appreciates the tireless work of Reps. Suzan DelBene (D-WA); Mike Kelly (RPA);
Ami Bera, MD (D-CA) and Larry Bucshon, MD (R-IN) and Senators Roger Marshall, MD (R-KS),
Kyrsten Sinema (D-AZ); John Thune (R-SD) and Sherrod Brown (D-OH) for their efforts to advance
this legislation.
The RRC, which served as a lead stakeholder and key collaborator in developing the bill, urges
Congress to act quickly to protect patients from unnecessary delays in care by advancing the
legislation in an end-of-year package in Congress this year.
More information about the RRC and the legislation is available at www.regrelief.org.
