Legislation seeks to minimize prior authorizations that ‘deny, delay and aggravate’
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Attempts to curtail prior authorizations for patients insured by Medicare Advantage plans have failed in back-to-back legislative sessions in 2019 and 2021, but a new bill has some experts hopeful that the third time is a charm.
“The previous bill had a $16 billion price tag from the Congressional Budget Office,” Robert W. Levin, MD, past president of the Florida Society of Rheumatology, president of the Alliance for Transparent and Affordable Prescriptions, and associate affiliate professor of medicine at the University of South Florida, told Healio. “The way the new bill is written now, the score is budget neutral. Regardless of whether it has more merit or not, that means this bill has a fighting chance.”
In June, a bipartisan group of legislators — U.S. Sens. Sherrod Brown, D-Ohio; Roger Marshall, R-Kansas; Kyrsten Sinema, I-Ariz.; and John Thune, R-S.D., as well as U.S. Reps. Ami Bera, D-Calif.; Larry Bucshon, R-Ind.; Suzan DelBene, D-Wash.; and Mike Kelly, R-Penn. — reintroduced the 2024 version of the Improving Seniors Timely Access to Care Act. The parallel bills — S. 4532 and H.R. 8702 — have attracted 51 and 182 cosponsors in the Senate and House of Representatives, respectively.
The bills have also gained support from hundreds of stakeholder groups, including the American Medical Association and the American College of Rheumatology.
“Prior authorization wastes physicians’ time, consumes scarce resources and significantly contributes to physician burnout,” AMA President Bruce A. Scott, MD, told Healio. “However, most importantly, prior authorization harms patients. It has become an increasing burden on physician practices as payors continuously expand the services requiring authorization in an effort to save money.”
Levin has seen all of this in his experience, both as a rheumatologist and an advocate.
“Prior authorizations by insurance carriers frustrate us, and perhaps the thinking is that maybe we will just give up and stop pursuing coverage for the medication,” he said. “They deny, delay and aggravate doctors and patients. Unfortunately, many providers and practices just give up trying to acquire the medications because of these tactics.”
For all of these reasons, and more, prior authorization reform is absolutely critical in the rheumatology space, according to Christina Downey, MD, chair of ACR’s Government Affairs Committee.
“Rheumatology operates on thin margins, so obtaining prior authorizations for treatments that are approved in 95% of cases wastes time and resources,” she said. “Practices require full-time staff just for managing prior authorizations which could be dedicated to managing patient care.”
Targeting ‘real-time’ decisions
A high CBO price tag is often the death knell of legislation on Capitol Hill, as it was the case for the previous version of the Improving Seniors Timely Access to Care Act in 2021. However, creative legislators and rule makers can — and often do — work around this problem.
In January, CMS approved the CMS Interoperability and Prior Authorization final rule, which experts believe improves the chances of passage for S. 4532/H.R. 8702.
That rule, set to take effect on Jan. 1, 2026, will require prior authorization decisions to be sent within 72 hours for urgent requests, or 7 days for standard requests. In addition, denials will require a specific reason, and payers must report certain prior authorization metrics on their website.
The rule additionally seeks to digitize and automate the process by requiring payers to maintain a prior authorization application programming interface. According to CMS, this interface can be used to “facilitate a more efficient electronic prior authorization process between providers and payers” by automating the end-to-end process.
“That rule took care of some of the aspects of the bill that would have cost money,” Levin said. “These regulatory changes accomplish what the old bill was designed to do.”
According to Scott, the current legislation before Congress requires the CMS to submit a report to Congress on the use of prior authorization in Medicare Advantage, and what constitutes real-time decisions for routinely approved services. The legislation also delegates explicit authority to CMS to implement this newly defined real-time prior authorization decision-making process for routinely approved services in Medicare Advantage.
It also gives explicit authority to the HHS secretary to enforce the real-time prior authorization processes for routinely approved services.
“HHS also has the authority to issue tighter timelines for health plans to make utilization management decisions, such as 24 hours for emergent services,” Scott said.
According to Levin, real-time decision making was the “main driver” of the CBO cost tied to the previous legislation.
Meanwhile, parts of the legislation related to mandating compliance with uniform electronic prior authorization technical standards, remain unchanged, Scott said.
“It bars Medicare Advantage plans from using faxes or proprietary payer portals, including robust transparency requirements — such as disclosure of policies and evidence used in formulating prior authorization, listing of all services subjected to prior authorization, and how many services are denied and overturned on appeal — and permitting insurers to create gold-carding programs,” he said.
Most health care professionals are all too familiar with these obstacles and tactics, and why legislation may be necessary to combat them. However, legislators in Washington, D.C., may still need convincing.
To that end, the AMA has conducted research on the details to show lawmakers exactly what physicians are experiencing.
A ‘compelling argument’ for reform
According to Scott, the AMA recently released a survey of physicians revealing that prior authorization interferes with patient care.
“The survey’s results make a compelling argument for prior authorization reform,” he said.
For example, nearly one in four physicians — 24% — reported that prior authorization has led to a serious adverse event for a patient in their care, including hospitalization, permanent impairment, or death.
Further data showed that 93% of physicians reported that prior authorization has a negative impact on patient clinical outcomes.
“The results also showed delayed care,” Scott said. “More than nine in 10 physicians — 94% — reported that prior authorization delays access to necessary care.”
Disrupted care was reported by 78% of physicians due to prior authorization struggles, while 53% noted lost workforce productivity among patients due to red tape.
“In the survey, physicians also reported high administrative burdens across major health plans when complying with prior authorization requirements and appeal procedures, forcing time and effort to be redirected away from patient care,” Scott said.
However, data alone may not be sufficient to convince legislators to pass a law. Advocacy and political pressure will be critical, experts said.
‘Grassroots messaging’ from ACR, AMA
According to Downey, the ACR is working closely with the congressional leaders of the legislation to help them garner as much support as possible.
“The ACR has grassroots messaging going to the House and Senate to communicate how much prior authorization reform would mean to ACR members and their patients,” she said.
The ACR policy team is also on the case, she added.
“They are communicating with Congressional leaders about legislative packages moving before the election and in the lame duck session, and fighting to include a prior authorization reform in one of those pieces of legislation,” Downey said.
The AMA, meanwhile, is making similar efforts. According to Scott, the group is engaging its Physician Grassroots Network to highlight the need for S. 4532 and H.R. 8702, promoting the bills on its social media channels and updating its FixPriorAuth.org website.
“We are also educating members of Congress on the need for this legislation as well as the importance of co-sponsoring and moving this bill forward in any end-of-year health care package,” he said, adding that physicians are encouraged to do their part by contacting their legislators.
According to Scott, the bipartisan and bicameral support for the bill, along with 500 stakeholder groups calling for passage, may be evidence that there is enough support in Congress to pass this “common sense” law.
“It will ensure that our patients receive vitally needed heath care without delay,” he said.
However, despite this optimism, Levin cautioned that its approval — or even its prospects for seeing a vote in either Congressional chamber — are far from guaranteed.
“Is this bill perfect? No,” he said. “Certainly, we would like it to apply to everyone who is ensured under federal jurisdiction. However, it is a good step, and translatable to other patients that may be covered under the federal government.”
Downey agreed, stating that the ACR hopes the legislation can streamline the journey from prescription to obtaining treatment for Medicare Advantage patients.
“And, in doing so, it may be a first step toward streamlining prior authorizations for patients covered by all payers,” she said. “If passed, the lives of patients and rheumatology care providers would be improved by granting access to care sooner, and with the use of fewer resources than previously required.”
According to Scott, this applies to patients across health care specialties.
“If the bill passes, the burden of prior authorization will be significantly reduced for patients and providers,” he said. “Patients will get more timely access to necessary care and encounter fewer adverse health outcomes, return to work more quickly and have better overall health outcomes.
“Physicians, meanwhile, will see the benefits of fewer administrative burdens, less time and resources wasted complying with administrative hurdles to get their patients the care they need, and reduce the obstacles that lead to physician burnout,” he added. “It’s a win-win.”
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