Rep. Suzan DelBene has heard too many disconcerting stories about prior authorization.

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A parent of one of her relatives had been scheduled for surgery as COVID-19 cases dropped and procedures started opening again, but had to cancel the surgery for lack of a timely prior authorization. In another scenario, a major insurer decided it needed prior authorization for cataract surgeries.

“There are so many stories that we've heard. If you or your loved ones are frustrated by the health care system, it's not just you. We know it's folks across the country and so many families,” said Rep. DelBene, a member of the House Ways and Means Committee and chair of the moderate New Democrat Coalition.

DelBene, who represents Washington’s 1st congressional district, has co-sponsored a bipartisan bill—the “Improving Seniors’ Timely Access to Care Act”—that would ease prior-authorization challenges physicians face in caring for patients covered by Medicare Advantage plans. She discussed how during an episode of “AMA Moving Medicine.”

Fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians. You took care of the nation. It’s time for the nation to take care of you. It’s time to rebuild. And the AMA is ready.

Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Find out how the AMA is tackling prior authorization with research, practice resources and reform resources.

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Rep. Suzan DelBene
Rep. Suzan DelBene has co-sponsored legislation to reduce prior authorization burdens in Medicare Advantage.

More than one-third (34%) of physicians responding to an AMA survey (PDF) reported that prior authorization led to a serious adverse event in a patient.

“The more that things are standardized, the more we can see prioritization streamlined, the more that providers are spending more time providing health care versus billing app forms,” DelBene said.

The legislation, also introduced in the Senate, cuts unnecessary delays in care by streamlining and standardizing prior authorization under the Medicare Advantage program. The legislation, which has more than 330 bipartisan co-sponsors in the House and Senate, incorporates all the major elements of a 2018 consensus statement developed by leading physician, hospital, medical group, health plan and pharmacy stakeholders. 

More specifically, the bill would:

  • Require Medicare Advantage plans to implement electronic prior-authorization programs that adhere to newly developed federal standards and are capable of seamlessly integrating into electronic health systems (versus proprietary health plan portals), as well as establish real-time decision-making processes for items and services that are routinely approved.
  • Mandate that plans report to the Centers for Medicare & Medicaid Services on the extent of their use of prior authorization and the rate of approvals and denials.
  • Require plans to adopt transparent prior-authorization programs that are reviewed annually, adhere to evidence-based guidelines, permit gold carding, and include continuity of care for individuals transitioning between coverage policies to minimize any care disruptions.
  • Hold plans accountable for making timely prior-authorization determinations and providing rationales for denials.

“One of my priorities has been to make sure that our policies have kept up with the way the world works today,” said DelBene.

Health systems use surprisingly outdated technology such as fax machines to process prior-authorization requests and exchange information, noted DelBene. There’s an opportunity to update and standardize technology to make this process quicker and more efficient, she emphasized.

“There's no reason for something that's routinely approved to be delayed,” said DelBene.

Prior authorization hurts patients, physicians, and employers. It’s time to #FixPriorAuth.

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The hope is the bill’s provisions could lead to broader changes in the private insurance market, where payers are investing more in modernizing prior-authorization systems, she said.

It is anticipated that the bill will be marked up in the Ways and Means Committee later this month.

Physicians and patients can visit fixpriorauth.org for additional information on the “Improving Seniors’ Timely Access to Care Act.” 

AMA Moving Medicine” highlights innovation and the emerging issues that impact physicians and public health today. You can catch every episode by subscribing to the AMA’s YouTube channel or the audio-only podcast version, which also features educational presentations and in-depth discussions.

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