​​​​​​​June 30, 2023: Advocacy Update spotlight on prior authorization regulations


The advocacy effort to push the Centers for Medicare & Medicaid Services (CMS) to finalize pending federal regulations that would overhaul prior authorization requirements within Medicare Advantage received a major boost following the release of a June 21 letter from Congress. The bipartisan, bicameral letter (PDF) to the Department of Health and Human Services (HHS) and CMS was anchored by Senators Sherrod Brown (D-OH), Roger Marshall, MD (R-KS), Kyrsten Sinema (I-AZ) and John Thune (R-SD), while the House letter was led by Representatives Suzan DelBene (D-WA), Mike Kelly (R-PA), Ami Bera, MD (D-CA) and Larry Bucshon, MD (R-IN). A bipartisan majority from both chambers—61 cosigners in the Senate and 233 cosigners in the House of Representatives—ultimately supported the letter. The AMA helped spearhead the letter and, in conjunction with the AMA’s Physicians Grassroots Network (PGN) and Patients Action Network (PAN), worked to ensure a robust number of federal elected officials cosigned this important communication to CMS.  

The letter urges CMS to both strengthen and expeditiously issue a final prior authorization regulation that includes many policies that align with the Improving Seniors’ Timely Access to Care Act, bipartisan legislation that generated close to 380 bipartisan cosponsors in the House and Senate in the 117th Congress. The same eight members of the House and Senate that led the Congressional sign-on letter to CMS introduced the Improving Seniors’ Timely Access to Care Act.  

Cosigners of the Congressional letter wrote that they: 

“…urge CMS to promptly finalize and implement these changes to increase transparency and improve the prior authorization process for patients, providers, and health plans. We also urge CMS to expand on these proposed rules by: 1) establishing a mechanism for real-time electronic prior authorization (e-PA) decisions for routinely approved items and service; 2) requiring that plans respond to PA requests within 24 hours for urgently needed care; and 3) requiring detailed transparency metrics.” 

The prior authorization regulation was released in Dec. 2022 and the comment period on the initial proposal closed in March 2023. The AMA submitted detailed comments (PDF) that largely support the vast majority of the concepts included in the proposed rule.   

The AMA was a strong supporter of the Improving Seniors’ Timely Access to Care Act and played a major role in securing enough cosponsors to ensure the bill passed the House of Representatives (PDF) in Sept. 2022. The legislation, however, stalled in the Senate due to a flawed $16 billion cost estimate from the Congressional Budget Office (CBO). Yet, the Biden administration’s pending prior authorization regulation provides a key pathway for overcoming the high price tag associated with enacting the legislation. If the final prior authorization regulation includes a mechanism for issuing real-time decisions, requirements to complete emergency requests within 24 hours, and detailed transparency metrics, these policies must, in turn, be incorporated into CBO’s baseline estimate for the legislation. In other words, incorporation of these policies could potentially lead to the $16 billion cost estimate being substantially lowered, thus increasing the odds of Congress passing the Improving Seniors’ Timely Access to Care Act, which would codify the provisions included in the regulation into law in the 118th Congress. 

The AMA greatly appreciates this bipartisan collection of House and Senate members sending the letter to CMS and will continue to work with the Biden administration and Congress to fully enact these major reforms to prior authorization requirements in Medicare Advantage.