• Academy Efforts Pay Off: Congress to Address Medicare Advantage Prior Authorization Abuses


    Lawmakers in the U.S. House of Representatives on Wednesday introduced legislation to rein in Medicare Advantage plans’ use of prior authorization that delay patients’ medically necessary care. This is a victory for the Academy and our two-year coalition effort to halt these interruptions. 

    The bipartisan Improving Seniors' Timely Access to Care Act of 2019 (HR 3107) would protect patients from unreasonable Medicare Advantage plan requirements that needlessly delay or deny access to medically necessary care. The legislation is sponsored by Reps. Suzan DelBene, D-Wash., Mike Kelly, R-Pa., Roger Marshall, MD, R-Kan., and Ami Bera, MD, D-Calif.

     Send a letter to your representatives in Congress asking them to cosponsor this 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. Unfortunately, many health plans now widely use prior authorization indiscriminately, creating hurdles and hassles for patients and their physicians that lead to treatment delays that may endanger patient health. 

    The process for obtaining this approval is frustrating, 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. 

    The bill would improve the current prior authorization system by requiring the Centers for Medicare & Medicaid Services to regulate the tool’s used by Medicare Advantage – including when it should be used. It includes an important surgical exception that allows surgeons to rely on the initial authorization if they need to perform additional services while the patient is in surgery. 

    The legislation would also bring greater transparency to prior authorization by requiring Medicare Advantage plans to report to CMS on the extent of their use of it and the rate of approvals or denials by service and/or prescription medication. 

    The Academy surveyed our members to better understand prior authorization’s effects on ophthalmology patients, a step mirrored by others in our eight-member Regulatory Relief Coalition, which includes rheumatology, urology and cardiology. The Academy found that nearly 90 percent of ophthalmologists have patients whose care was negatively affected as result of prior authorization delays. 

    Our survey also showed that:

    • Nearly two in five respondents say their patients often abandon recommended courses of treatment due to issues related to prior authorization requests.
    • Ninety percent of respondents report being asked by insurance plans to switch a stable patient’s medication, even though there was no medical justification for the request.
    • Prior authorization is contributing to rising health care costs at the physician practice level. More than half of respondents employ staff who work exclusively on these requests.
    • Nearly 86% of respondents say that the burdens associated with prior authorization have increased significantly over the last five years. 

    The legislation is the result of a relentless, two-year effort in which the Academy led seven other physician specialty organizations in a push for reform. We now shift our efforts to securing co-sponsors and a companion bill in the Senate. The Academy’s goal is to have the bill move before the end of the year.