Prior Authorization in Medicare Advantage : Lawmakers Call for Streamlined Process

CMS has proposed a rule to simplify prior authorization in government-sponsored health insurance programs. However, some lawmakers are urging the agency to do more. A bipartisan coalition of 233 representatives and 61 senators have written a letter to CMS requesting that the proposed rules be expanded and that the changes be finalized quickly to enhance the administrative process in Medicare Advantage (MA), Medicaid, and Affordable Care Act exchange plans.

The lawmakers are specifically requesting that CMS:

• Implement real-time electronic prior authorization decisions for routine services.
• Mandate that plans respond to prior authorization requests within 24 hours for urgent care.
• Demand detailed transparency metrics.

If paired with the Improving Seniors’ Timely Access to Care Act, the prior authorization regulations would establish electronic prior authorization processes for MA plans, hasten prior authorization time frames, lessen administrative burden on providers and health plans, enhance transparency regarding prior authorization requirements, and broaden beneficiary protections.

The lawmakers expressed their strong recommendation for CMS to promptly finalize and implement these changes in order to enhance transparency and improve the prior authorization process for patients, providers, and health plans. They also expressed satisfaction that the proposed rules align with the bipartisan and bicameral Improving Seniors’ Timely Access to Care Act. This act proposes a balanced approach to prior authorization in the Medicare Advantage program, aiming to eliminate obstacles to timely access to care for patients and enable providers to allocate more time to treating patients rather than paperwork.

MA has faced significant challenges with prior authorization. Despite long-standing concerns over the administrative process in the private program, a recent survey conducted by the Medical Group Management Association revealed that little progress has been made. Of the medical groups surveyed, 84% reported that prior authorization requirements in MA had increased in the past 12 months, while less than 1% reported a decrease in requirements. As MA continues to grow, it is crucial that its expanding membership has access to necessary healthcare when it is needed.