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ACP Urges Senate to Pass Legislation Aimed at Improving the Medicare Advantage Prior Authorization Process

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Legislation will protect patients from unnecessary delays and reduce administrative burdens for physicians by streamlining prior authorization processes

Oct. 7, 2022 (ACP) — The American College of Physicians is encouraging the U.S. Senate to pass the Improving Seniors' Timely Access to Care Act, which would streamline and standardize prior authorization processes in the Medicare Advantage (MA) program and move it into the electronic age.

ACP is urging the Senate to pass the bill in the remaining weeks of the legislative year. The bill has widespread support and has already passed the House. “The legislation will take important steps toward protecting patients from unnecessary delays in care and reducing administrative burdens on physicians,” said Dr. Ryan D. Mire, president of ACP.

Many patients and ACP members will benefit if the bill becomes law. MA enrollment has more than doubled from 2007 to 2022, according to a Kaiser Family Foundation report, and 48% of all eligible Medicare beneficiaries (28.4 million people) are enrolled in MA plans.

“ACP has long recognized the burden that onerous prior authorization requirements place on physicians and patients,” said David Pugach, ACP vice president for governmental affairs and public policy. “Prior authorization is the No. 1 burden to physician practice and a major impediment to the patient-physician relationship and patient care.”

The legislation meshes perfectly with the ACP Patients Before Paperwork initiative, launched in 2015 to reinvigorate the patient-physician relationship and eliminate unnecessary burdens on physician practice.

Specifically, the legislation will:

  • Mandate that all MA plans adopt electronic prior authorization capabilities to streamline the prior authorization approval process.
  • Protect beneficiaries from disruptions in care due to prior authorization requirements as they transition between MA plans.
  • Standardize the process and procedures for reporting electronic prior authorization criteria to MA plans.
  • Mandate that all MA plans issue prompter prior authorization decisions, including real-time decisions for routinely approved services. If plans are unable to meet these standards due to extenuating circumstances, they must issue decisions within a 72-hour and 24-hour time period for regular and urgent services, respectively.
  • Require faster prior authorization decisions for all other services in commercial insurance plans within Medicare.

If passed, the bill's requirements will be implemented by the fourth plan year after enactment, according to Pugach. “It will hopefully provide a model on how to improve prior authorization processes and meet the needs of insurers without unnecessarily delaying care for patients or burdening physicians,” he explained.

The prospects for the bill's passage this year are mixed. “It has strong bipartisan support, with about 45 cosponsors in the Senate,” Pugach said. “The challenge is that Congress is out until mid-November and will return with a limited number of legislative days to address its unfinished business, which means that even a commonsense bill like this still needs to be prioritized.”

ACP has written to congressional leaders in favor of the bill's passage and will continue to urge the Senate to act without delay. As Pugach put it, “the Improving Seniors' Timely Access to Care Act is an opportunity to enact meaningful reforms that will benefit seniors across the country.”

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Back to the October 7, 2022 issue of ACP Advocate