番茄社区

Medical groups are optimistic that a recently reintroduced bill to rein in prior authorization has a better chance of passage now than it did last time around.

"We believe the bill is poised for adoption this year," Katie Orrico, JD, CEO of the American Association of Neurological Surgeons, said in an email to 番茄社区. "While the Senate did not officially move the legislation in the 117th Congress last year, 61 senators to HHS and CMS [Centers for Medicare & Medicaid Services] urging the agency to finalize its prior auth rules. This, coupled with passage by the House, signifies strong support for the legislation."

The was first introduced in the House in May 2021; it passed on a voice vote in September 2022. That 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 Advantage (MA) plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials
• Encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians

"Seniors and their families should be focused on getting the care they need, not faxing forms multiple times for procedures that are routinely approved. This takes away valuable time from providers who on average spend 13 hours a week on administrative paperwork related to prior authorization," Rep. Suzan DelBene (D-Wash.), the bill's chief sponsor, with cosponsors Mike Kelly (R-Pa.), Ami Bera, MD (D-Calif.), and Larry Bucshon, MD (R-Ind.) the day the bill passed the House. "The Improving Seniors' Timely Access to Care Act will make it easier for seniors to get the care they need by cutting unnecessary red tape in the healthcare system. We urge the Senate to quickly take up this legislation and get it to President Biden's desk."

But the measure, which applied only to MA plans, hit a roadblock in the Senate in the form of a from the Congressional Budget Office (CBO).

"By placing additional requirements on plans that use prior authorization, we expect [the bill] would result in a greater use of services," the CBO report said. "We expect Medicare Advantage plans would increase their bids to include the cost of these additional services, which would result in higher payments to plans." The CBO estimated that the bill would cost the federal government $16.2 billion over a 10-year period.

The bill went nowhere in the Senate, but in the meantime, in January, CMS . The new rules -- which apply to all federally governed health plans, including those in Medicare, Medicaid, the Children's Health Insurance Program, and the Affordable Care Act's federally run health insurance exchanges -- require payers to send prior authorization decisions within 72 hours for urgent requests and within 7 calendar days for non-urgent requests; beginning in 2026, impacted payers also must provide a specific reason for denied prior authorization decisions.

The rules also require that payers publicly report certain prior authorization metrics annually by posting them on their website, and they include provisions to encourage electronic submission of prior authorization requests. The agency that the rules "[do] not apply to prior authorization decisions for drugs."

The American Medical Association (AMA) was generally in favor of the new CMS rules, but "we were a little bit disappointed that they weren't as aggressive as we would like them to be," AMA President Bruce Scott, MD, told 番茄社区 in an interview conducted with a press person present. For example, the AMA wanted to require a 24-hour deadline for urgent requests, rather than 72 hours, and 3 days on non-urgent requests, rather than 7 days, "and the implementation is not going to be until 2026 -- 2025, in some cases," he said.

But Scott sounded upbeat about chances of passage for the latest bill, which was introduced in both the House and the Senate on June 12. The current legislation, which is similar to the previous bill, "has [been] tweaked ... to hopefully lower that scoring of the price tag, so we think there's going to again be broad bipartisan support," he said.

Orrico agreed. "The bill sponsors have made several changes to lower the costs based on the input they received from the Congressional Budget Office," she wrote. "While there are no guarantees, we anticipate that the changes should bring the cost down closer to zero. CBO will discount the costs to the extent that the bill mirrors the final rule CMS published earlier this year, thus paving the way for passage."

"The timing is uncertain at this time, but now that the bill has been introduced, we hope the CBO will swiftly analyze it, and Congress will advance it on a fast-track pathway," she added. "The alternative option is to incorporate this into any must-pass legislation this year."

The provisions requiring more transparency from health plans about their use of prior authorization are particularly important, Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association (MGMA), said in a statement. (Disclosure: Gilberg is a member of the 番茄社区 editorial board.)

"By requiring MA plans to publicly reveal what services are subject to prior authorization, how many are approved, and how long on average they take to approve -- this legislation will drive plan accountability," he said. "MGMA looks forward to working with Congress to advance policies that ensure that no health plan can stand in the way of life-saving healthcare simply to increase their bottom line."

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