Efforts to restrict prior authorizations under Medicare Advantage took a major step forward with introduction of a bipartisan bill in both chambers of Congress on Wednesday.
The Improving Seniors’ Timely Access to Care Act of 2024 would enshrine into statute prior authorization restrictions similar to those the Centers for Medicare and Medicaid Services implemented in a final rule published in January.
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Under the CMS rule, insurers in the Medicare, Medicaid, Children's Health Insurance Program and exchange markets must respond to non-urgent prior authorization requests within seven days and to urgent requests within 72 hours.
The legislation unveiled Wednesday codifies the agency's ability to set time limits, but leaves specifics up to future regulations. The bill suggests a time limit "such as 24 hours."
Among the requirements in the bill are:
- An electronic prior authorization system with standardized processes for transactions and clinical attachments.
- Improved transparency around prior authorizations for patients and providers.
- Extensive reporting on rates of prior authorization requests, denials, appeals, denials overturned, resolution times, and on the technology used to make determinations, such as artificial intelligence.
- Federally mandated timeframes for electronic prior authorization requests, including expedited determinations, real-time decisions for routine matters and other requests.
- Regulatory agency reports to Congress on program integrity efforts and other ways to further improve the process.
The House unanimously approved a similar bill in 2022, during the previous Congress. The measure stalled after the Congressional Budget Office estimated it would raise healthcare spending by $16 billion because people would be able to get more care.
That price tag is now likely to be much lower because the CMS rule already does many of the same things, thus reducing the cost of congressional intervention. In addition, Senate aides said specific requirements for real-time notifications and expedited decision-making were modified to bring down the budget score.
"With the improvements we’ve made, there is no reason we should not quickly get this bill signed into law,” said Sen. Dr. Roger Marshall (R-Kan.), the lead sponsor of the measure in the Senate.
Other lawmakers agreed, though they still would like to see a new CBO score. "People are committed to doing something," said Rep. Dr. Larry Bucshon (R-Ind.), who is a sponsor of the House bill.
Bucshon predicted the legislation would pass after the elections, when a slew of other healthcare-related bills must advance through Congress before the new year. "I would see this as an end-of-the-year-package type thing," he said. "I think that will probably happen."
Healthcare groups including the American Medical Association, the American Hospital Association and the Better Medicare Alliance, which represents insurers, praised the legislation.
