Sign in Subscribe
Legislative bills

Bipartisan Bill Aims to Streamline Prior Authorization Process Under Medicare Advantage

Strategic Insights

— 1 min read

Representatives Suzan DelBene, Mike Kelly, Ami Bera, John Joyce, and Senators Roger Marshall and Mark Warner have introduced a revised Improving Seniors' Timely Access to Care Act, with the goal of modernizing the prior authorization process under Medicare Advantage. This bill aims to reduce unnecessary delays in care and allow healthcare providers to focus on treating patients rather than justifying procedures.

Key Takeaways:

  • The current prior authorization system, used by health plans to reduce unnecessary care, often results in multiple faxes or phone calls by clinicians, taking precious time away from delivering care.
  • Prior authorization is the number one administrative burden identified by healthcare providers, with nearly three out of four Medicare Advantage enrollees experiencing unnecessary delays due to the practice.
  • The bill focuses on holding Medicare Advantage plans accountable and transparent to the American public, with goals including:

+ Establishing an electronic prior authorization process with standardization for transactions and clinical attachments.

+ Increasing transparency around Medicare Advantage prior authorization requirements and use.

+ Clarifying HHS' authority to establish timeframes for e-prior authorization requests.

+ Expanding beneficiary protections to improve enrollee experiences and outcomes.

+ Requiring HHS and other agencies to report to Congress on program integrity efforts.

  • The bill received endorsements from over 500 national and state organizations representing patients, physicians, Medicare Advantage plans, hospitals, and other stakeholders.
  • In January 2023, HHS finalized regulations that made many of the changes proposed in the legislation, and this bill would codify these wins to ensure no future administration could undo them.

Statistics:

  • 34.5 million people are enrolled in Medicare in 2025, including nearly 760,000 in Washington.
  • The Congressional Budget Office determined that the legislation would result in a zero cost to American taxpayers in 2024.
  • 75% of requests that were originally denied by Medicare Advantage plans were ultimately approved in recent years.
  • MA plans incorrectly denied beneficiaries access to services even though they met Medicare coverage rules, according to a recent HHS report.

Sources:

  • "Bipartisan Bill to Improve Seniors' Healthcare Access Introduced in Congress" (United States House of Representatives -- Congresswoman Suzan DelBene)
  • "Improving Seniors' Timely Access to Care Act" (United States Senate and House of Representatives)
  • "HHS Report on Medicare Advantage Prior Authorization" (United States Department of Health and Human Services)
  • "Congressional Budget Office Report on the Improving Seniors' Timely Access to Care Act" (Congressional Budget Office)

Read more