The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) and LeadingAge are both tracking the progress of legislation each has endorsed to modernize Medicare Advantage (MA) prior authorization processes.

The bill, “Improving Seniors' Timely Access to Care Act (H.R. 3514),” passed out of the House Ways and Means Committee on July 15, and now awaits further legislative action, albeit in a compressed congressional calendar with August recess and midterms clouding the legislation’s chances for full congressional approval this year.

Nisha Hammel, vice president of reimbursement policy and population health, AHCA/NCAL, in a blog post Prior Authorization Bill Passed by the House Ways & Means Committee said H.R. 3514 formalizes many of the Centers for Medicare and Medicaid Services's (CMS’s) existing prior authorization requirements in statute, reinforcing their permanence and helping to promote more consistent implementation and adherence across MA plans​.

Hammel said the key reporting requirements in the act include:

• Services requiring prior authorization

-              A list of every item and service subject to prior authorization during the previous plan year.

• Approval and denial rates

-              The number and percentage of prior authorization requests approved and denied.

-              Reported both in the aggregate and broken down by each individual item/service.

• Appeal activity

-              The percentage and number of denied requests that were appealed.

• Appeal outcomes

-              The number of appeals resolved.

-              The percentage and number of appeals that resulted in the service being approved.

-              Reported by item/service and by each level of appeal, including judicial review.

• Use of AI and decision-support technology

-              The percentage and number of approvals and denials made using AI, machine learning, clinical decision-support tools, or similar technologies.

-              A description of the technologies used.

• Decision time frames

-              The average and median number of hours from receipt of a complete request to the plan's determination.

-              Reported by item/service.

• Incomplete requests

-              The percentage and number of requests excluded from the turnaround-time calculation because the plan determined the submission lacked required documentation.

• Changes during treatment

-              Reporting on instances where a provider determined that a different or additional service was medically necessary after prior authorization had already been approved (e.g., during surgery), including whether the plan ultimately approved the additional service.

LeadingAge’s Take

LeadingAge also supports the bill. Nicole Fallon, vice president, integrated services and managed care policy, LeadingAge, in a blog post House Committee Advances Bipartisan Bill to Streamline Medicare Advantage Prior Authorization said Rep. Greg Murphy (R-N.C.), a physician, spoke the most forcefully in support of the legislation, lending his voice to the broad bipartisan support of the committee.

“He said it is time to ‘defang the insurance industry,’ arguing that plans have ‘weaponized’ prior authorization to deny care, harm patients, and maximize profits,” Fallon said.

LeadingAge, she said, “has long supported the legislation and continues to support the amended bill. It would require MA plans to establish an electronic prior authorization program that cannot rely on fax or proprietary plan portals unless they meet standards set by the Department of Health and Human Services (HHS) Secretary to standardize and streamline electronic requests.”

“MA plans also would have to give contracted providers clear information on which items and services require prior authorization, the policies and procedures used to make decisions, the criteria used for determinations, and the documentation providers must submit. This would move providers away from the current guessing game,” Fallon said, noting some of the highlights of the legislation.

What’s Next?

Fallon said “given the bill’s broad bipartisan support including nearly 300 members of the House, it is eligible to be fast-tracked for a House floor vote. The House has previously passed this legislation and would be expected to do so again.”

Following this action, the bill would require Senate approval before being transmitted to the president for his signature. “LeadingAge is cautiously optimistic about the bill’s passage, but this legislation has met with year-end obstacles before,” Fallon said.

Questions or comments? Contact Patrick Connole at pconnole@parkplacelive.com.