Congress Debates Bill to Automate Prior Authorization in Medicare Advantage Plans

Posted on Monday, September 30, 2019 12:48 PM

The House of Representatives’ Small Business Committee convened a hearing on utilization management and barriers to care in small medical practices.  The hearing focused on the application of prior authorization within Medicare Advantage plans and the associated challenges because of prior authorization requirements.

The Improving Seniors’ Timely Access to Care Act, a bill that would automate the prior authorization process in Medicare Advantage plans, clearly was theme of the hearing. This automation would be through electronic submission of prior authorization requests with real-time determinations by the MA plans. The legislation encourages integration of the electronic prior authorization submission into electronic medical record systems. The Secretary of Health and Human Services would be tasked with developing standards in conjunction with stakeholder input. In addition, certain transparency requirements would be put in place. These include:

  • A list of services and items subject to prior authorization;
  • The percentage of prior authorization requests approved during the previous plan year by the plan for each item and service;
  • The percentage of requests that were initially denied and then subsequently appealed, and the percentage of such appealed requests that were overturned for each such item and service; and
  • The average amount of time elapsed from request submission to determination

This legislation would impact all provider types that contract with Medicare Advantage plans that require prior authorization.

Source: NAHC Report

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