In the wake of a divisive election season, there is one important sign of bipartisanship prevalent on Capitol Hill. A majority of the members of the U.S. House of Representatives—135 Democrats and 86 Republicans—have officially co-sponsored the bipartisan Improving Seniors’ Timely Access to Care Act of 2024 (H.R. 8702).
The co-sponsorship milestone is a signal to House leadership that the bill warrants consideration before the 118th Congress ends. The AMA has been a proponent of the bill and worked to help secure support from lawmakers, along with leaders from other associations and societies in the house of medicine. Nearly 450 health care organizations—including the 50 state medical associations—support the Improving Seniors’ Timely Access to Care Act.
A companion bipartisan bill in the Senate, S. 4532, earlier this year garnered the support of the majority of the members of that chamber, with 54 co-sponsors from both sides of the aisle.
Reps. Mike Kelly (R-Pa.), Suzan DelBene (D-Wash.), Ami Bera, MD (D-Calif.) and Larry Bucshon, MD (R-Ind.), introduced the House bill. Sens. Roger Marshall, MD (R-Kan.), Kyrsten Sinema (I-Ariz.), John Thune (R-S.D.) and Sherrod Brown (D-Ohio) introduced the Senate version.
“The bipartisan and bicameral support for the bill is evidence that this is a commonsense proposal that deserves to be passed,” said AMA President Bruce A. Scott, MD, who has written an AMA Leadership Viewpoints column about the importance of fixing prior authorization.
The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
When could the bill be considered?
Federal lawmakers are waiting for the Congressional Budget Office (CBO) to provide them an updated cost assessment that will guide them on what financial impact passing the act would have on the nation’s budget.
A slightly different version of the bill that was introduced during the 117th Congress came with a $16 billion price tag. The version of the bill before the 118th Congress has had all but about $4 billion of the previous score folded into the spending baseline following the finalization of a regulation that encompasses much of the Improving Seniors’ Timely Access to Care Act.
Proponents hope the CBO’s cost assessment for the revised House version of the bill will show the legislation doesn’t have a cost. That conclusion would help the bills pass the House and the Senate when lawmakers return to Washington in December.
In the 117th Congress, the House passed the earlier version of the Improving Seniors’ Timely Access to Care Act, but the Senate never considered it because of the high cost the CBO projected.
In late October, the CBO reportedly told key sponsors of the House and Senate legislation that the expected cost of the new version of the bill was $0. This should be a boon to its prospects to pass before the end of the 118th Congress.
What’s in the bill?
The Improving Seniors’ Timely Access to Care Act 2024 would streamline and standardize how Medicare Advantage uses prior authorization.
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. The secretary of the U.S. Department of Health and Human Services has explicit authority 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.
In addition, the bill:
- 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.
Why change is a must
Insurers once rarely used prior authorization, deferring to it when extremely pricier interventions were involved. Now, prior authorization is sometimes used for even the simplest generic medication.
These denials are causing real harm for patients in Medicare Advantage, along with those covered by other public and private insurers. The AMA and others are calling for reforms, including speeding up response times and maintaining continuity of care.
Nearly one-quarter of the 1,000 physicians the AMA surveyed (PDF) in late 2023 reported that prior authorization has led to a serious adverse event for a patient in their care, including 7% that said prior auth led to a patient’s disability or permanent bodily damage, congenital anomaly or birth defect or death.
Patients, doctors and employers can learn more about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.
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