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- Prior Authorizations Final Rule May Pave Way for Legislative Action
In September 2022, the House passed the Improving Seniors’ Timely Access to Care Act, a prior authorization bill to better serve patients and reduce unnecessary administrative burdens for clinicians. Since then, the Senate and House have been working with the Centers for Medicare and Medicaid Services (CMS) to advance the legislation to the President’s desk, but the bill’s cost has been a factor.
Following new regulatory changes to prior authorization rules by the CMS, the cost of the legislation is expected to decrease – which improves the chances of the bill one day becoming law.
The bipartisan legislation would:
- Establish an electronic prior authorization process that would streamline approvals and denials;
- Establish national standards for clinical documents that would reduce administrative burdens for health care providers and Medicare Advantage plans;
- Create a process for real-time decisions for certain items and services that are routinely approved;
- Increase transparency that would improve communication channels and utilization between Medicare Advantage plans, health care providers, and patients;
- Ensure appropriate care by encouraging Medicare Advantage plans to adopt policies that adhere to evidence-based guidelines
- Require beneficiary protections that would ensure the electronic prior authorization serves seniors first.
On January 18, the CMS released a final rule that makes important reforms in prior authorization programs for medical services. The rule is a direct result of important advocacy efforts taken by the CAP together with the American Medical Association and other physician organizations to address prior authorization in government-regulated health plans. As a result of the recent final rule, legislators now see a path forward toward enacting this legislation and making these reforms into law.