WASHINGTON, D.C. – Senator Thom Tillis recently joined a bipartisan group of Senators in reintroducing the Improving Seniors’ Timely Access to Care Act. This bipartisan, bicameral legislation streamlines the prior authorization process under Medicare Advantage (MA), allowing seniors to get the care they need and helping health care providers put patients over paperwork.

“Arbitrary and unnecessary delays in care that stem from current prior authorization processes are unacceptable,” said Senator Tillis. “This legislation will alleviate administrative burdens on physicians, cut red tape and, most importantly, ensure patients have uninterrupted access to quality care.”

Background:

Prior authorization is a tool used by health plans to reduce unnecessary care by requiring health care providers to get pre-approval for medical services. But it’s not without fault. The current system often results in unconfirmed faxes of a patient’s medical information or phone calls by clinicians which takes precious time away from delivering quality and timely care. Prior authorization continues to be the #1 administrative burden identified by health care providers, and three out of four Medicare Advantage enrollees are subject to unnecessary delays due to prior authorization. In recent years, the Office of the Inspector General at the U.S. Department of Health and Human Services (HHS) raised concerns after an audit revealed that Medicare Advantage plans ultimately approved 75% of requests that were originally denied. More recently, HHS OIG released a report finding that MA plans incorrectly denied beneficiaries’ access to services even though they met Medicare coverage rules. 

Health plans, health care providers, and patients agree that the prior authorization process must be improved to better serve patients and reduce unnecessary administrative burdens for clinicians. In fact, leading health care organizations released a consensus statement to address some of the most pressing concerns associated with prior authorization. 

Specifically, the bill would:

1. Establish an electronic prior authorization process for MA plans including a standardization for transactions and clinical attachments.
2. Increase transparency around MA prior authorization requirements and its use.
3. Clarify CMS’ authority to establish timeframes for e-PA requests including expedited determinations, real-time decisions for routinely approved items and services, and other PA requests.
4. Expand beneficiary protections to improve enrollee experiences and outcomes.
5. Require HHS and other agencies to report to Congress on program integrity efforts and other ways to further improve the e-PA process.

This legislation is supported by over 370 national and state organizations, including the North Carolina Medical Society, the North Carolina Chapter of the American College of Physicians, the North Carolina Health Care Facilities Association, Susan G. Komen Foundation, National Council for Mental Wellbeing AARP, National Association for Home Care & Hospice, National Alliance on Mental Illness, Alzheimer's Association, and the American Hospital Association. 

Bill text is available HERE.

A section-by-section summary can be found HERE.

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