House Committee Advances Bill to Streamline Prior Authorization

WASHINGTON — In a moment of comity that’s becoming increasingly rare in Congress, the House Ways & Means Committee voted unanimously by voice vote to send to the House floor a bill to improve prior authorization procedures in Medicare Advantage (MA) plans.

“This kind of opportunity has become all too rare, and I hope that we can utilize this moving forward … to address the challenges that we are facing,” Rep. Adrian Smith (R-Neb.) said during the hearing to mark up the bill. “While prior authorization requirements have an important role to play in protecting our healthcare system from fraud and abuse, it has become clear that improvements are needed to ensure outdated technology or unnecessarily complicated paperwork does not stand in the way of seniors accessing needed healthcare … While this legislation may not be enough to address every concern with the prior authorization process, it’s a huge step toward a more modern, more efficient future.”

Rep. Mike Kelly (R-Pa.) agreed. “I think it’s really good for the country to see that we can actually work on projects and pieces of legislation together,” he said. “The most important thing for any senior is that they have peace of mind, and there’s nothing worse than waiting to hear, if you have a medical problem, that ‘We’re still waiting to get authorization for it.’ I think it’s the most unfair thing we can do to people … This is something that moves us in the right direction.”

The bill in question is H.R. 8487, the Improving Seniors’ Timely Access to Care Act. It includes several measures aimed at streamlining prior authorizations — the requirement that healthcare providers get insurer approval ahead of time before performing certain procedures or ordering particular tests or treatments. Among other provisions, the bill would:

• Require all MA plans to use an electronic prior authorization system. “No more phone calls, no more faxes,” said Rep. Suzan DelBene (D-Wash.), the bill’s chief sponsor.
• Establish a process for “real-time” decision-making. Plans would have to respond to routine prior authorization requests within 7 days — as opposed to the 14 days now required by law — and to expedited requests within 24 hours, rather than the current 72 hours.
• Require more transparency in the prior authorization process. MA plans would have to report on the number of prior authorization requests they receive, their rates of approval and denial, and their rate of successful appeals.

“We must deliver a quality product that fully allows providers to do their job,” DelBene said of the bill, which also has 306 cosponsors. “And unfortunately the cumbersome and antiquated prior authorization process is too often getting in the way … Today, our committee will take a major step forward in resolving this problem.”

Several committee members who are also healthcare providers expressed their support for the bill. “I ran for Congress because I saw people making healthcare decisions who had never seen a patient,” said Rep. Brad Wenstrup, DPM (R-Ohio), a podiatrist. “This bill will be revolutionary for patients and healthcare providers across the country.” Wenstrup added that the bill has long been a “top priority” for the House Doctors’ Caucus, of which he is a co-chair, and that it will help to reduce workforce shortages.

“I was at one of my local hospitals and I saw four nurses, and their only job was to get prior authorization for the pediatric ophthalmology clinic before they could treat somebody,” he said. “First of all, we have a nursing shortage and I think there’s a lot better things that the nurses can be doing. And that’s not why they got into patient care.”

Rep. Greg Murphy, MD (R-N.C.), a urologic surgeon, also applauded the measure. “The purpose of [prior] authorization was to try to keep too many tests from being ordered, or try to prevent something that was ordered too much by some physicians, and I understand that,” he said. “But the problem is, it has gotten so far out of control — it has hurt patients.”

Committee chair Richard Neal (D-Mass.) also thanked some outside groups for their support of the measure, including the American Medical Association, American Hospital Association, “and the insurance industry.” However, insurer groups appear to be divided on the bill.

The Better Medicare Alliance, a trade group for Medicare Advantage plans, issued a press release Wednesday in support of the bill before the vote was taken. “H.R. 8487 will build on the work the Medicare Advantage community has already undertaken to modernize prior authorization while protecting its essential function in facilitating high-value, clinically appropriate care,” said alliance president and CEO Mary Beth Donahue. “We urge members of the Ways & Means Committee to vote ‘yes’ and look forward to continuing to partner with our bipartisan champions in Congress to secure passage of this bill on the House floor in short order.”

But America’s Health Insurance Plans (AHIP), the trade group for health insurers, has not been supportive. “Unfortunately, certain provider organizations are targeting the MA program and its sustained success to advance their own political agenda and secure financial gains for their members,” AHIP president and CEO Matthew Eyles wrote May 27 in a letter to Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure discussing the legislation.

“Even doctors agree that variations in treatment can lead to unnecessary, costly, or inappropriate medical treatments that can harm patients,” Eyles said. He cited a 2017 survey published in PLOS One, which found that two-thirds of physicians themselves believed that at least 30% of the healthcare services they delivered were unnecessary. “What would motivate provider organizations like the American Medical Association to undermine the MA program? … The answer is both evident and simple: They seek to undermine the valuable quality-improving, cost-saving, and waste-reducing tools of the program for their own financial benefit,” Eyles added.

AHIP did not respond by press-time to a request for comment on today’s action in the House.