Nation's Leading Medical Specialty Organizations Applaud Congressional Leaders' Introduction of Legislation to Improve Oversight and Transparency in Prior Authorization

By Policy and Advocacy Brief posted 06-05-2019 16:38


New data highlights the need for prior authorization reform to ensure patients' timely access to medically necessary care.

The Regulatory Relief Coalition, a group of eight national medical specialties including the AUA, today pledged support for the bipartisan Improving Seniors' Timely Access to Care Act of 2019 (H.R. 3107), legislation that would protect patients from unreasonable Medicare Advantage plan requirements that needlessly delay or deny access to medically necessary care. Reps. Suzan DelBene (D-WA-01), Ami Bera, MD (D-CA-07), Roger Marshall, MD (R-KS-01) and Mike Kelly (R-PA-16) sponsored the legislation. Currently, Medicare Advantage plans require physicians to obtain advance approval before physicians can provide certain services to their patients. This prior authorization process is intended to control costs by reducing medically unnecessary tests and procedures.  However, physicians are reporting that MA plans have imposed increasingly onerous prior authorization requirements for medical services that are adversely affecting patient access to necessary medical care. Dr. Robin Shaw of Urological Associates of Savannah, P.C., in Savannah, GA, noted, “Prior authorizations are the worst. We are getting 100 percent of the CY Medicare fee schedule; however, the administrative burden is ridiculous. I have had to hire someone additional to do pre-certs due to the requirements they have placed on us for authorizations.”

The process for obtaining this approval is lengthy, typically requiring physicians or their staff to spend the equivalent of two or more days each week negotiating with insurance companies. This time would better be spent taking care of patients, especially because the vast majority of these requests are ultimately approved.

Physicians report devastating results from the worst prior authorization delays, including blindness, loss of function and tumor growth.

The Improving Seniors' Timely Access to Care Act is based on a consensus statement on prior authorization adopted by leading national organizations representing physicians, hospitals and health plans. The bill would improve the current prior authorization system by requiring the Centers for Medicare & Medicaid Services (CMS) to regulate Medicare Advantage plans on prior authorization's use.

The legislation would also bring greater transparency to the prior authorization process by requiring Medicare Advantage plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials by service and/or prescription medication. Over 100 members of Congress called for such reform in a bipartisan letter to CMS last year.

In conjunction with the bill's introduction, the Regulatory Relief Coalition, the group of eight medical specialty societies, released results of a physician survey that details the extent to which abusive prior authorization policies are putting patients at risk and increasing burdens on physician practices. 

The survey results include the following:

  • An overwhelming number of physicians (87%) report that prior authorization has a significant (40%) or somewhat negative (47%) impact on patients' clinical outcomes.
  • A third of physicians (32%) report that their patients often abandon their treatment because of prior authorization.
  • Three-quarters of physicians (74%) report that during the past five years, stable patients have been asked to switch medications by their health plan even though there was no medical reason to do so.
  • Eighty four percent of physicians report that the burden associated with prior authorization has significantly increased over the past five years, with more than half of all practices subjected to 11 or more requests each week, with many finding these requests exceed 40 per week.

"For more than two years, the Regulatory Relief Coalition made it our responsibility to chip away at barriers that deny our patients timely access to medically necessary care, and the walls enabling prior authorization's abuse are about to come down," said George A. Williams, MD, president of the American Academy of Ophthalmology, one of the coalition's members.  

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