Washington, DC – U.S. Senator Sheldon Whitehouseintroduced the Prior Authorization Relief Act. Whitehouse’s bill would alleviate administrative burdens associated with prior authorizations – a tool that requires health care providers to secure approval from health insurance plans before delivering medicines and services for a patient – so that patients can get prescribed care faster.
“Americans are understandably frustrated with our health care system, and one of the many reasons is prior authorization. Prior authorization is a tool used by the insurance industry to drive up administrative costs, confuse patients, and delay medically necessary care,” said Whitehouse. “My legislation aims to untangle the administrative web health care providers are caught in, which will reduce health care spending and increase the quality of care for patients.”
Over 35 million prior authorization requests were submitted to Medicare Advantage health insurance plans in 2021. When used correctly, prior authorization can be an important tool to ensure that a prescribed medicine or service is medically necessary and cost-effective. Instead, prior authorization too often leads to delays in care and increased administrative red-tape for health care providers. A 2022 Surgeon General Advisory report links administrative burdens with health care burnout, less clinician time with patients, and even harm to patients. The Surgeon General specifically called on insurers to “reduce requirements for prior authorizations, streamline paperwork requirements, and develop simplified, common billing forms.”
The Prior Authorization Relief Act would:
- Require Centers for Medicare and Medicaid Services (CMS) to perform an audit across all prior approvals required in Medicare Advantage insurance plans for medicines and services.
- Require CMS to standardize prior authorization requirements across those medicines and services identified through the Agency’s audit. The bill would standardize prior authorization protocols across those medicines and services to reduce providers’ administrative time and costs associated with providing the most utilized and cost-effective treatments for their Medicare Advantage beneficiaries.
- Create an exemption for providers excelling in the Medicare Shared Savings Program, eliminating certain prior authorization requirements in Medicare Advantage. The bill rewards providers in accountable care organizations in the Medicare Shared Savings Program which produce savings for Medicare against their predetermined benchmarks in a given performance year, by exempting those providers from fulfilling prior authorization requirements for the medicines and services identified through CMS’s audit in the subsequent performance year for their Medicare Advantage beneficiaries.
“While there has been some progress in reining in abusive prior authorization practices of Medicare Advantage plans, there is lots more that needs to be done in order to ensure that plan enrollees are able to access medically necessary care,” said David Lipschutz, Co-Director of the Center for Medicare Advocacy. “We applaud Senator Whitehouse’s efforts to continue to hold these plans accountable.”
“As the nation’s leading physician organizations providing accountable care, America’s Physician Groups supports Senator Whitehouse’s proposed reforms to prior authorization in Medicare Advantage,” said Susan Dentzer, CEO of America’s Physician Groups. “Unfortunately, we know well that there is much waste in American health care, and much provision of low-value care that is of little use to – and can actually harm – patients. Prior authorization is an essential tool for weeding out low-value or no-value care, but as with all tools, it must be used carefully and judiciously, with reasonable timelines and with the rationale for prior authorization decisions made abundantly clear to patients. Standardizing approaches in prior authorization across the Medicare Advantage program will help to build confidence that this tool can be used appropriately, both to protect patients and ensure greater affordability of health care overall. We heartily support far broader use of gold card programs for value-based care providers across Medicare Advantage plans, as well as within the Medicare Shared Savings Program, as the Senator’s legislation proposes.”
