Academy Advocacy Moves Administration on Prior Authorization Improvements

When the U.S. House of Representatives unanimously passed a bill to reform prior authorization in Medicare Advantage plans in September, the Academy knew making it law was not assured.

The day the House debated the bill, the  Congressional Budget Office released a report that estimated the bill would significantly raise Medicare costs by billions of dollars over 10 years due to greater use of services.

All the bill’s lead sponsors have taken issue with the Congressional Budget Office score. Ophthalmology champion and Academy Visionary Award winner Rep. Larry Bucshon, MD, R-Ind., said the agency missed the mark because its “task is to score legislation based on current law, not on the current state of affairs where entities are failing to follow the law.”

Bucshon was referencing an April inspector general report, which outlined the ways Medicare Advantage plans were using prior authorization to deny care that would have been covered under current law.

As part of our ongoing efforts to get this legislation signed into law, the Academy immediately reached out to congressional leaders to push back against the Congressional Budget Office’s assumptions. The Academy and some of our Regulatory Relief Coalition partners met with U.S. House Speaker Nancy Pelosi’s office last week to discuss options for advancing the House-passed prior authorization legislation before the end of the year.  

In response, congressional leaders engaged the administration urging the Centers for Medicare & Medicaid Services (CMS) to advance a rule to require Medicare Advantage plans to “improve the electronic exchange of health care data and streamline processes related to prior authorization. ...” If that rule is published prior to the bill being taken up by the Senate, it could substantially lower the bill’s projected cost.

The Oct 13. announcement that the White House Office of Management and Budget is reviewing the rule was the latest result of an all-out Academy effort to reform prior authorization by the end of the year.

We continue to push for Congress to include this bill in any end-of-year legislative package. The Senate version has 45 bipartisan cosponsors. If the CMS rule comes out before the Senate debates the bill, it could lower the expected cost and encourage more senators to support this commonsense reform to the prior authorization process in the Medicare Advantage program.