• Prior Authorization Fix Moves Through Congress, Thanks to Nudge from the Academy


    The Academy is helping advance an important congressional fix to existing prior-authorization burdens. Lawmakers in the U.S. House of Representative are considering legislation that would allow physicians to electronically submit Medicare Part D prior-authorization requests. To aid this proposal, Cathy G. Cohen, the Academy’s vice president for government affairs, last week accepted an invitation to brief congressional staff on how prior authorization affects physicians and our patients. We urged them to adopt the legislation as a step toward removing other administrative barriers to timely care. 

    The Standardizing Electronic Prior Authorization for Safe Prescribing Act of 2018 — or H.R. 4841 — would allow electronic submission of Part D prior-authorization requests. This law would reduce access delays by resolving coverage issues before prescriptions for such drugs are transmitted. We believe this change would lessen burdens on physicians. 

    To give this proposal a boost, its sponsor, Rep. David Schweikert, R-Ariz., requested the Academy join him to explain its value to congressional staffers. The Academy shared how our patients are affected by existing policies. Our presentation laid out current costs and time burdens associated with prior authorization requests. 

    This bill only addresses Medicare Part D services. Still, we believe that its passage would set a precedent for lawmakers to follow for other parts of Medicare. It should improve recordkeeping, which is a common problem throughout medicine. Each week, the Academy hears from members whose reimbursements were denied —despite receiving prior authorization — because of private health plans’ issues with records. 

    The Academy is persisting in an ongoing effort to engage Congress and other stakeholders on the issue of prior authorization reform. A broad coalition of physician groups joined us. Our coalition also sent a letter to Centers for Medicare & Medicaid Services Administrator Seema Verma. We recommended that her agency provide prior authorization guidance to private plans. 

    These steps help advance our effort to reduce onerous prior-authorization requirements that routinely postpone Medicare Advantage beneficiaries’ medically necessary care. Our message to Congress this week reinforces the cost to our patients — their constituents. 

    We know that Medicare Advantage organizations are requiring prior authorization beyond what is reasonable. When this happens, it can unnecessarily delay care that our patients need. 

    For example, some plans now require prior authorization for each visit for age-related macular degeneration. In these cases, the plans are essentially approving all the requests. This creates a barrier to care — which is illegal. 

    We’re also urging CMS to include this issue in its “Patients Over Paperwork” initiative, an Academy-supported program. It seeks to eliminate unnecessary, burdensome regulations that prevent physicians from spending more time with patients. 

    Urge Your Lawmaker to Fix Prior Authorization to Allow More Focus on Patient Care

    You can aid our advocacy with a letter to your lawmaker. Urge them to support legislation that would reduce prior authorization burdens for patients and physicians.