What’s the news: Earlier this month, a bipartisan congressional group introduced an updated version of the Improving Seniors’ Timely Access to Care Act in the House and Senate (H.R. 8702; S. 4532).
The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles. The AMA supports the latest version of this legislation to reform the use of prior authorization in Medicare Advantage. It was, once again, introduced by Sens. Roger Marshall, MD (R-Kan.), Krysten Sinema (I-Ariz.), John Thune (R-S.D.), and Sherrod Brown (D-Ohio), as well as Reps. Mike Kelly (R-Pa.), Suzan DelBene (D-Wash.), Ami Bera, MD (D-Calif.) and Larry Bucshon, MD (R-Ind.).
“We thank the sponsors for writing the bill so it will attract even more support,” said AMA President Bruce A. Scott, MD, an otolaryngologist in private practice in Louisville, Kentucky. “Our patients know all too well that prior authorization needs a dramatic overhaul. We think this is the year to get this bill over the finish line.”
In the 117th Congress (2021–2022), an earlier version of this measure garnered more than 378 total bipartisan co-sponsors in the House and Senate and also passed the full House of Representatives. In addition, the legislation secured endorsements from more than 500 outside organizations, including the AMA and numerous national and state medical societies.
Unfortunately, the version of this bill that passed the House in the 117th Congress was never considered in the Senate because it produced a score of $16 billion from the Congressional Budget Office (CBO), thus necessitating modifications to lessen the bill’s fiscal imprint. While an electronic prior authorization rule that was finalized by the Biden administration in January lowered the $16 billion score substantially, the recently introduced bill is amended to ensure it ultimately scores as close to $0 as possible.
Use the AMA Physicians Grassroots Network to contact your members of Congress today and ask them to support this vital piece of legislation.
Why it’s important: As the latest AMA survey shows (PDF), doctors nationwide see the impact of prior authorization on patient care virtually every day, in the form of denials and delays that have negative clinical effects and sometimes even worse.
An alarming 24% of physicians reported prior authorization has led to a serious adverse event for a patient in their care. More specifically, these shares of physicians surveyed by the AMA said that prior authorization led to a:
- Patient’s hospitalization—19%.
- Life-threatening event, or required intervention to prevent permanent impairment or damage—13%.
- Patient’s disability or permanent bodily damage, congenital anomaly, birth defect or death—7%.
The legislation requires the Office of National Coordinator for Health Information Technology and the Centers for Medicare & Medicaid Services (CMS) to submit a report to Congress on the use of prior authorization in Medicare Advantage and what constitutes “real-time decisions” for “routinely approved services.”
The bill also delegates explicit authority to CMS to implement this newly defined real-time prior authorization decision-making process for routinely approved services in Medicare Advantage. Finally, the legislation delegates explicit authority to the secretary of the U.S. Department of Health and Human Services to enforce the real-time prior authorization processes for routinely approved services and issue tighter timelines for health plans to make utilization management decisions, such as 24 hours for emergent services.
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Notably, the bipartisan measure is unchanged insofar as it still:
- Mandates compliance with uniform electronic prior authorization technical standards.
- Bars Medicare Advantage plans from using faxes or proprietary payer portals.
- Includes robust transparency requirements such as disclosure of policies and evidence used in formulating prior authorization, listing all services subjected to prior auth, how many services are denied and overturned on appeal, and more.
- Permits insurers to create gold-carding programs.
“This legislation will streamline the prior authorization process so physicians can offer patients safe, timely and affordable care,” Dr. Scott said. “Those decisions should be made between patients and their doctors without being second-guessed by insurers. The bipartisan and bicameral support for the bill is evidence that this is a commonsense proposal that deserves to be passed.”
For more on Dr. Scott’s perspective, read his AMA Leadership Viewpoints column, “We must fix prior authorization to protect our patients.”
Learn more: Explore further why the AMA is fighting to fix prior authorization and how it is pushing for these essential changes at the federal and state levels to remove obstacles to care and protect patients from harms resulting from prior auth.
At the 2024 AMA Annual Meeting, the House of Delegates took action to hold insurers legally accountable for the patient harms of prior authorization and require them to provide clear information about how a prior authorization denial was determined and why.
The AMA has achieved recent wins in prior authorization and other critical areas (PDF) for physicians.
