Congress is eying changes to Medicare Advantage that would crack down on prior authorization tactics insurers use to rein in healthcare costs but can affect how providers care for patients.
Rep. Susan DelBene (D-Wash.), Mike Kelly (R-Pa.), Ami Bera (D-Calif.) and Larry Bucshon (R-Ind.) reintroduced a bill Thursday that aims to quicken the prior authorization process and require more transparency about how often plans deny providers' requests. Healthcare lobbyists believe the proposal could see movement this year.
"This continues to be a thorn in the side of our practices. It is such an administrative burden," said Drew Voytal, associate director of government affairs for the Medical Group Management Association.
Under the bill, Medicare Advantage plans must establish electronic prior authorization programs and provide "real-time decisions" for some services that are routinely approved by insurers, to be determined by the HHS secretary.
The proposal would require Medicare Advantage plans with prior authorization requirements to submit an annual report to the HHS secretary listing which services require prior approval and how many requests were approved, denied and overturned after initial denials in the previous plan year. They would have to tell HHS the average and median amount of time between the submission of a prior authorization request and a determination from the plan.
Plans would also need to make the information available to providers they contracts with and tell beneficiaries and providers the criteria for making prior authorization determinations. The bill encourages insurers to adopt prior authorization programs that adhere to evidence-based medical guidelines, according to DelBene's office.
"The majority of the healthcare community agrees that prior authorization needs to be reformed," DelBene said in a statement. "This bipartisan legislation creates sensible rules for the road and will offer transparency and oversight to the prior authorization process."
A similar proposal was introduced in 2019 but never passed due to insurers' concerns, mostly about some of the bill's transparency requirements.
The updated version of the bill only removes a requirement that the transparency information be published on a public website.
"We've worked closely with stakeholders from all perspectives on this including insurers to make sure these changes are practical, realistic, and in the best interest of the patient," said Nick Martin, a spokesperson for DelBene. When the bill was last introduced in 2019, it had 280 cosponsors.
The Trump administration also proposed a rule that aimed to require insurers to build APIs between payer and provider systems for information related to Medicaid, the Children's Health Insurance Program and exchange plans. CMS had said it wanted to later include Medicare Advantage beneficiaries data too. The Biden administration does not appear to have taken any action on the rule.
Prior authorization reform has long been a goal of provider groups like the American Medical Association, which says physicians are increasingly being told to get approval from insurance plans before a patient can access drugs, tests or treatments.
In a 2020 AMA survey, 15% of physicians polled said prior authorization requirements always delayed access to necessary care for patients, while 39% said that often happened and 40% said it happened sometimes.
Prior authorization can also have an impact on physician practices, with 85% saying requirements pose a high or extremely high burden, and 40% saying they have staff who exclusively work on getting approval from insurance companies for treatment.
"The AMA believes that PA is overused, costly, inefficient, opaque and responsible for patient care delays," AMA CEO and executive vice president James Madara wrote in a letter to DelBene and other sponsors of the bill Thursday.
A 2021 report by the not-for-profit CAQH estimated the healthcare industry could save $417 million annually by automating prior authorization requests.
Insurers, meanwhile, argue prior authorization helps reduce inappropriate care.
"Misaligned incentives and an incomplete view of a patient's medical history often leads to too much care, or worse, harmful treatment," said Kristine Grow, senior vice president of communications for America's Health Insurance Plans. The group didn't comment specifically on the bill.
She said AHIP supports "collaborative efforts" to improve the prior authorization process and pointed to its "Fast PATH Initiative," in which six insurers used electronic prior authorization over the course of six months, resulting in faster decision times.
It didn't have an impact on the approval rate, however, with participating providers receiving authorizations 60% of the time. But it did speed up the response rate—within the six month period studied, the median time between prior authorization submission and a decision from the health plan was three times faster than before the pilot, falling from 18.7 hours to 5.7 hours.
Some electronic health vendor providers are even getting involved in the effort. In March, EHR vendor Epic and Humana announced they would connect their software to manage prior authorizations and make Humana member information available to providers at the point of care. The two started integrating their technologies in 2019, and now have enabled data sharing for more than 500,000 Humana members.
Regional health plans have also utilized electronic portals to streamline prior authorization, said Dr. Connie Hwang, chief medical officer at the Alliance for Community Health Plans. By creating electronic portals between payers and providers, she said insurers have been able to speed up the response rate for decisions on member care—in some cases, providing responses in two minutes, Hwang said—as well as create analytics dashboards that highlight for providers past decisions made around patient care in specific areas. These dashboards can help highlight for providers evidence-based guidelines for care and can cut down the cost of care, by comparing the price of similar therapies, Hwang said.
One barrier for these systems is providers' outdated technology.
"Many of our plans certainly have created these electronic prior authorization portals," Hwang said. "What's interesting is that not all practices really pick up on that. Some actually are quite attached to the fax machine still these days. But we're trying to encourage a lot more of that."
Along with electronic portals, Hwang said regional plans have also focused on constant communication with their provider networks. Building relationships has been key for diluting some of the tension around the issue, she said. The ACHP is also a proponent for more value-based relationships between payers and providers, as a way to introduce more accountability and cut down on unnecessary care across providers.
She said blanket prior authorization requirements—like "real-time" decision making—could pose a challenge for the healthcare system, since care can depend on payers' and providers' region, population and the services available. Because healthcare is local, she wondered about how the HHS would use a report that highlighted individual insurers prior authorization data.
"Healthcare relationships are inherently local," Hwang said. "Depending on which metrics you take, and what you are benchmarking, I think there would be more research that's needed to figure out like what number characterizes the regional and local relationships in the plan, the providers and the care that's being provided."