House Bill Seeks to Cut Red Tape on Prior Authorizations in Medicare

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WASHINGTON — Medicare Advantage insurers need to be more clear about their prior authorization policies, according to a group of House members.

“When I was practicing I routinely dealt with burdens and processes like this,” Rep. Larry Bucshon, MD (R-Ind.), who formerly worked as a thoracic surgeon, said at a press conference Thursday announcing the introduction of H.R. 3173, the Improving Seniors’ Timely Access to Care Act.

“It chained doctors, nurses, and other healthcare workers to their desk instead of spending time taking care of patients,” he said. “We definitely need increased transparency in this prior authorization process. We need to eliminate the red tape; we need to modernize the system, making it more user-friendly, so that we can get more quick decisions made in a timely manner, especially for routine care.”

“Prior authorization” refers to requirements by health insurers that providers get authorization for a particular treatment in advance in order for the insurer to reimburse for it. Prior authorization has long been the bane of many providers’ existence, with its accompanying paperwork, faxes, and phone calls.

Requirement for Reporting on Approval, Denial Rates

The bill that Bucshon was discussing would establish an electronic prior authorization process and would require the Department of Health and Human Services to create a process for real-time decisions for items and services routinely approved, explained Suzan DelBene (D-Wash.), one of the bill’s chief sponsors. It would require Medicare Advantage plans to report on their use of prior authorization and their rate of approvals and denials, and would encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines, she said.

“We’ve seen overwhelming support for this measure in the previous Congress,” said DelBene. “We have over 280 co-sponsors … 218 is the magic number in the House, so this shows that we have strong bipartisan support for this legislation to move it.”

The bill has also received the support of more than 70 leading healthcare provider and patient advocacy organizations around its introduction, she added.

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The bill to regulate prior authorization in Medicare Advantage plans has 280 cosponsors, said Rep. Suzan DelBene (D-Wash.). (Photo courtesy livestream by Rep. DelBene’s office)

Rep. Mike Kelly (R-Pa.), who formerly worked in the automotive business, contrasted health insurers with the auto industry. “On a lot of these things, it basically comes down to being able to provide the care you need in a timely fashion so that you’re not left in limbo,” he said.

If a problem arises with a car warranty, “I can get on the phone and actually call somebody at General Motors, or call somebody at Hyundai or Kia or Toyota, and I can get a direct answer and they’ll give me authorization to go ahead and do something more than what was prescribed,” said Kelly.

“If you want to keep a customer coming back to you, give them good service. If you want to lose them forever — don’t, and they’ll never be back. We have to have some kind of standards that are set; there has to be some kind of clarity,” Kelly added.

“Not Adding to Clinical Care”

Rep. Ami Bera, MD (D-Calif.) agreed with that analogy: “I do think healthcare is a service industry — we’re there to serve our patients,” he said. “When I first was practicing, you had prior authorizations, but they were really there for the rare, unexpected procedures, and it was totally appropriate … Fast forward to today when up to 40% of the physician time is spent on administrative activities that are not clinically related.”

“If you talk to many of the doctors that are out there practicing today, they have to hire one to three additional staff just to fill out paperwork, and it’s not adding to clinical care,” said Bera. “We didn’t go to medical school to learn how to fill out papers; we went to medical school to learn how to take care of our patients.”

The bill “is an important first step to bring this practice into the 21st century, to make sure we put the patient at the center of healthcare delivery,” he said.

George Williams, MD, who spoke on behalf of the American Academy of Ophthalmology, gave an example of how prior authorization can interfere with care: “Just yesterday, I evaluated a 67-year-old gentleman with sudden loss of vision and examination. He had advanced diabetic retinopathy with ocular bleeding and swelling in his retina. He was no longer able to read or drive, and was therefore unable to work.”

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Prior authorizations are “granted over 90% of the time, indicating that the prior authorization process rarely decreases cost, but typically delays access to care,” said ophthalmologist George Williams, MD. (Photo courtesy livestream by Rep. DelBene’s office)

The patient “required immediate treatment with injection of FDA-approved medication into his eyes,” said Williams, an ophthalmologist in Royal Oak, Michigan. “This is the standard of care. Unfortunately he had a Medicare Advantage plan that requires prior authorization for any treatment, and if approved, the required treatment would be with a drug not approved by the FDA for this indication.”

“It is my experience that such approval typically takes a few to several days … and since he required immediate treatment, I proceeded with treatment with a sample of the FDA-approved medication I believed was the best therapy. It’s unlikely that any of these services will be covered by his insurance,” Williams said.

“Even when treatment is not emergent, the vagaries of prior authorization require my practice to expend considerable time and resources to obtain approval,” Williams continued. “Such approval is granted over 90% of the time, indicating that the prior authorization process rarely decreases cost, but typically delays access to care. This delay in access requires patients to return for additional and otherwise unneeded office visits that increase our patient’s treatment burden. It is an inefficient way to deliver healthcare.”

Moving Through the Process

The legislation was introduced on May 13, and now must be assigned to a House committee. DelBene and Kelly are both members of the House Ways & Means Committee, “and we’re working to move it through there,” DelBene said, adding that there will also be a companion bill in the Senate. Kelly said the group sponsoring the bill has “really good allies in the Senate” as well.

Asked why the bill applies only to Medicare Advantage plans and not to commercial insurers, Bera said: “When we first started thinking about this, obviously we were thinking about this broadly, but we wanted to build a big coalition and Medicare Advantage seemed to be the right place to start. And I’d say this as a starting point, not an ending point” in terms of eventually including other types of plans.

DelBene chimed in that “this also helps set the precedent. When we show how well this can work, it also will put more pressure on others to adopt a similar model going forward.”

As for the insurance industry’s response to the measure, “we worked with insurers all the way through this process,” DelBene said. Bera noted that the group “took every effort to work with health plans; we don’t want to do an adversarial approach. We took their input and tried to incorporate that where appropriate.”

In response to an email from MedPage Today, a spokesman for America’s Health Insurance Plans, the trade group for the health insurance industry, said the group was currently analyzing the bill.

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    Joyce Frieden oversees MedPage Today’s Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow

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