番茄社区

Is the second time the charm? That's what many members of Congress, physician leaders, and healthcare advocates are wondering regarding a bill that would further regulate the use of prior authorization in Medicare Advantage (MA) and other federal health programs.

"It's hard to get anything done in Washington, D.C. these days, but we're optimistic this is something that can move forward," Bruce Scott, MD, president of the American Medical Association (AMA), said Wednesday in a phone interview. "I think that's because the bill makes a lot of sense. Prior authorization is frustrating for doctors, drives our burnout, and wastes our time, but more importantly, it harms patients. It needs to be rightsized; it needs to be fixed ... We're hoping the legislature makes all that official."

The measure, known as the "," currently has 221 House cosponsors and 54 Senate cosponsors. It would establish an electronic prior authorization process for MA plans that would standardize transactions and clinical attachments, increase transparency around MA prior authorization requirements, and require HHS and other agencies to report to Congress on their efforts to improve the electronic prior authorization process.

Although an earlier version of the bill unanimously passed the House in 2022, it didn't gain any traction in the Senate; this was mostly thought to be due to the fact that the Congressional Budget Office (CBO) had at $16.2 billion over 10 years. However, in December 2022, CMS proposed its own prior authorization regulations that included many of the provisions in that first version, such as mandating that "impacted payers" -- including MA plans as well as managed Medicaid plans and plans in the Children's Health Insurance Program -- share prior authorization decisions within 72 hours for expedited requests and within 7 calendar days for "non-urgent" requests. The proposed rules also require payers to include specific reasons for denials.

In addition, the rules would require certain "eligible" providers and hospitals to report metrics related to the adoption of electronic prior authorization.

So legislators reworked the bill and replaced some of the cost-generating provisions with budget-neutral ones. On Wednesday, the CBO was unofficially telling legislators' offices that the expected cost of the new version of the bill was $0, greatly increasing its chances of passage.

"The [act] just leapt over the very last hurdle to having a bill considered by congressional leaders for inclusion in an end-of-year package -- we now have a 'preliminary estimate' of ZERO score from the Congressional Budget Office," Peggy Tighe, legislative counsel to the Regulatory Relief Coalition, told 番茄社区 in an email. The coalition is a group of physician specialty organizations advocating for regulatory burden reduction in Medicare.

Tighe noted that in addition to the House and Senate cosponsors, the measure "is supported by nearly 500 healthcare organizations including several from the insurance industry ... and is backed by dozens of reports and studies showing evidence of need. Seniors enrolled in Medicare Advantage can be assured that these plans will be transparent in their dealings and that electronic prior authorization will be used to expedite important decisions about their healthcare."

The American Association of Neurological Surgeons/Congress of Neurological Surgeons is also optimistic about the bill's chances in the "lame duck" session of Congress at year's end, Charlotte Pineda, the group's vice president of health policy and advocacy, said in an email. "We commend the efforts of the Senate and House sponsors. They showcase the best of bipartisan, bicameral teamwork and proactive engagement in working with all stakeholders impacted by prior authorization."

The Medical Group Management Association was similarly upbeat. "With the support of a bipartisan majority of the House and Senate, nearly 500 endorsing stakeholder organizations, a minimal expected CBO score, and little to no opposition, there is no reasonable explanation for Congress not to pass the bill by the end of the year other than total dysfunction," Anders Gilberg, the group's senior vice president for government affairs, told 番茄社区 in an email. (Disclosure: Gilberg is a member of the 番茄社区 editorial board.)

The AMA's Scott described some of his own frustrations with prior authorization. "It's not uncommon for me to get on the phone with a person [from the insurance company] who is supposed to be a peer; many times they have not gone to medical school, are not a doctor, and don't know anatomy," he said. "There was one where I wanted to get a CT scan in an area of the neck and the person was denying it because they thought it was for [something in] the nasal sinus. I said, 'You do understand the tumor is in the person's voice box, in their neck?' The person didn't know the part of the body the tumor was growing in and she was making the decision as to whether it would be allowed or not."

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