Prior Authorization

To assist in removing barriers to timely access to care, SVS has joined the Regulatory Relief Coalition (RRC), a group of national physician specialty organizations advocating for regulatory burden reduction in Medicare so physicians can spend more time treating patients. Together, we advocate for common-sense reform of Medicare Advantage (MA) organizations’ use of prior authorization to ensure that prior authorization is not a barrier to timely access to care for the patients we serve. 

Prior authorization is a cumbersome process that requires physicians to obtain pre-approval for medical treatments or tests before rendering care to their patients. The process for obtaining this approval is lengthy and typically requires physicians or their staff to spend the equivalent of 2 or more days each week negotiating with insurance companies — time that would be better spent taking care of patients. 

Prior authorization is often imposed on services that are very unlikely to be over-utilized and are eventually approved 90-100% of the time. In these cases, and others, prior authorization not only prevents seniors from receiving medically necessary, sometimes lifesaving, care in a timely manner but expends unnecessary time and money for plans, providers and caregivers.

Legislative Victory

In September 2022, The Improving Seniors’ Timely Access to Care Act passed the US House of Representatives with more than 320 co-sponsors and over 500 endorsing organizations representing patients, health care providers, medical technology and biopharmaceutical industry, health plans and others seeking to ensure that bureaucratic hurdles do not stand in the way of physicians providing medically necessary patient care.

The Improving Seniors’ Timely Access to Care Act would improve prior authorization by:

  • Establishing an electronic prior authorization (ePA) program;
  • Standardizing and streamlining the prior authorization process for routinely approved services, including establishing a list of services eligible for real-time prior authorization decisions;
  • Ensuring prior authorization requests are reviewed by qualified medical personnel; and
  • Increasing transparency around MA prior authorization requirements and their use.

The RRC is currently working alongside Sens. Roger Marshall (R-KS), Kyrsten Sinema (D-AZ), John Thune (R-SD) and Sherrod Brown (D-OH) to advance this legislation and strongly urge the Senate to act quickly to protect patients from unnecessary delays in care by bringing the legislation to the Senate floor for a vote.

Endorsing Organizations

Physician Coalition Lauds Proposed Rule Mirroring House-Passed Bill to Streamline Prior Authorization in Medicare Advantage Program

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In early December, the RRC enthusiastically lauded the Centers for Medicare & Medicaid Services (CMS) for its released proposed rule.

The proposed rule’s provisions regarding Medicare Advantage (MA) plans closely align with the Improving Seniors’ Timely Access to Care Act (S. 3018/H.R. 3173). If adopted, the proposed rule and the legislation would both require MA plans to address prior authorization requests more promptly — streamlining and simplifying the process to ensure the timely provision of patient care.

The proposal shares many elements of the legislation for improving prior authorization. Most notably, the rule and the bill both:

  • Seek to reduce care delays and improve patient outcomes;
  • Aim to advance interoperability and improve prior authorization processes by requiring MA plans to adopt electronic prior authorization (E-PA);
  • Ensure MA plans respond to prior authorization requests within specific timeframes;
  • Require public reporting on the use of prior authorization with specific and detailed transparency on MA prior authorization;
  • Support efforts to waive or modify prior authorization requirements based on provider performance; and
  • Acknowledge that health plans’ proprietary interfaces and web portals through which providers submit their requests remain inefficient and burdensome.

See proposed rule here

Furthermore, the proposal and the bill also closely align with the stated rationale for improving prior authorization processes. Both the rule and the bill acknowledge that prior authorization:

  • Plays an important role in utilization management, but it can be misused or overused, creating considerable challenges for patients, providers, and payers;
  • Presents a serious health risk for patients when care is delayed;
  • Increases provider and payer burden due to inconsistent payer policies, provider workflow challenges, and unpredictable use of electronic standards; and
  • Contributes to significant provider burnout.

See Full Press Release here