National legislation aims to simplify Medicare Advantage prior authorizations

Sen. Roger "Doc" Marshall, MD

Primary care physicians support legislation that could improve patient care while cutting time spent obtaining prior authorizations for medical services in Medicare Advantage plans.

Meanwhile, lawmakers hope for a fall vote on at least one version of the identical bills in the U.S. Senate and House of Representatives.

Rep. Suzan DelBene

The “Improving Seniors’ Timely Access to Care Act of 2022” has amassed more than 500 endorsements from organizations across the health care industry and bipartisan support from dozens of legislators in the House and Senate.

Sen. Roger “Doc” Marshall, MD, R-Kansas, introduced the “Improving Seniors’ Timely Access to Care Act,” S. 3018, with the goal of improving health care for seniors while reducing the workloads for physicians and their staff, Will Bensur, Marshall’s press secretary, told Medical Economics.

With cosponsorships from 37 senators and more than 300 representatives, lawmakers took a key step move at the end of July, when the House Ways & Means Committee advanced it by voice vote. That sets up a possible floor vote in the fall, House sponsor Rep. Suzan DelBene, D-Washington, said in a news release.

“It is 2022 and even Congress has moved beyond the fax machine,” DelBene said in a news release. “The health care system is complicated in the best of times. Doctors and their patients shouldn’t have to call or fax back and forth with insurance companies or send documents multiple times for procedures that are approved over 95 percent of the time.”

As an obstetrician/gynecologist, Marshall experienced firsthand medical paperwork burdens that contribute to workplace burnout, while potentially hurting patient outcomes. Physicians practice medicine to put “patients over paperwork,” and Marshall and the other lawmakers recognize that, Bensur said.

“We want to make it easier for physicians to spend more time with their patients,” Bensur said. “In the context of burnout, I think that's getting people back to what they're passionate about, why they're doing this. This certainly can help with that.”

How it works

The bill would establish a prior authorization process to streamline approvals and denials, with national standards for clinical documents to reduce administrative burdens for physicians and Medicare Advantage plans, according to Marshall’s office.

Marshall and the other lawmakers acknowledge prior authorizations are an important cost management tool – with potentially serious consequences for patients and physicians.

Prior authorizations may delay or deny care for seniors who need it, according to 2018 and 2022 reports by the U.S. Department of Health and Human Services’ Inspector General. The 2022 review found 13% of prior authorization requests were denied, even though they met Medicare coverage rules, and 18% of payment requests that were denied, met the rules, but had errors from workers or in system processing. The audit’s title stated the problem: “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care.”

Physicians speak up

In a 2021 survey by the American Medical Association (AMA), physicians slammed prior authorization for its effects on patient outcomes, along with being a serious drag on office productivity and morale.

In that survey, physicians reported an average of 41 PAs per physician, per week, taking up to 13 hours of work time a week. The PA burden is high or extremely high, according to 88% of respondents.

AMA and the American Academy of Family Physicians (AAFP) are among the medical groups supporting the legislation.

“The federal government needs to automate and streamline prior authorization, as well as reduce the overall volume of prior authorizations to improve patient care and minimize physician burden,” AAFP said in a July news release announcing its letter urging lawmakers to streamline the PA process.

“We know firsthand from family physicians that prior authorization creates an administrative burden for physicians and other clinicians,” AAFP said. “The manual, time-consuming processes used in prior authorization programs burden family physicians and their practice staff, divert valuable resources from direct patient care and can delay the start or continuation of necessary treatment, leading to lower rates of patient adherence to treatment and negative clinical outcomes.”