Providers and payers agree that the prior authorization process needs to improve, but they have widely differing views on how to accomplish that. Legislators have now stepped in with their own plan to streamline the prior authorization process under the Medicare Advantage program, which has gained support from both sides of the aisle.
Dubbed the Improving Seniors’ Timely Access to Care Act of 2021, the legislation would require the Centers for Medicare Medicaid Services to enhance the way Medicare Advantage plans use prior authorization, which is the process through which insurers determine whether to cover a treatment or service.
The bill, if enacted into law, would establish an electronic prior authorization process, said Rep. Dr. Larry Buschon (R-Ind.), a co-sponsor of the bill. It would also require the secretary of the Department of Health Human Services to establish a real-time decisions process for items and services that are routinely approved and would order Medicare Advantage plans to report on their use of prior authorization and the rate of approvals or denials to CMS.
“As a provider, I know firsthand the burden prior authorization can bring and how it truly can take time away from caring for a patient,” Buschon said in an email. “When prior authorization is not properly managed or misused, it can lead to delays in care for patients and result in administrative burdens for providers.”
About 30% of physicians say that prior authorization has led to a serious adverse event for a patient in their care, according to a survey of 1,000 physicians conducted by the American Medical Association in 2020.
Buschon, along with a bipartisan group of policymakers Reps. Suzan DelBene (D-Wash.), Mike Kelly (R-Pa.) and Dr. Ami Bera (D-Calif.), introduced the legislation in April.
As of Oct. 8, it had secured 227 co-sponsors in the U.S. House of Representatives — a bipartisan majority.
“With that majority, I feel strongly that we can get this legislation across the finish line and I will continue to push for its consideration,” said DelBene, chief sponsor of the bill, in an email. “We aren’t getting rid of prior authorization. We are making commonsense reforms to this process so that it doesn’t become a barrier to seniors in receiving timely, life-saving care.”
Support for the legislation rose amid the backdrop of a controversial new policy implemented by Aetna over the summer.
Since July 1, the health insurer has required prior authorization for all cataract surgeries. Unsurprisingly, ophthalmologists vehemently opposed this policy.
“Since the new policy went into effect in July, we’ve had a constant stream of communications from our members telling us how their patients and practices are suffering,” said Dr. David Glasser, secretary for federal affairs for the American Academy of Ophthalmology, in an email. “Patients with advanced cataracts are being told they haven’t lost enough vision to justify surgery. Ophthalmologists report that when they appeal denials of care, Aetna puts them through a ‘peer-to-peer’ review that is often led by doctors who don’t specialize in ophthalmology…We estimate that cataract surgery has been delayed for approximately 10,000 to 20,000 patients in July alone.”
But, according to Aetna, more than 99% of cataract precertification cases in July were compliant with turnaround time standards.
“Based on our decades of experience in reducing unnecessary surgeries, a multi-year, multi-state pilot on reducing unnecessary cataract surgeries and national clinical guidelines and literature on surgeries, we believe up to 20% of all cataract surgeries may be unnecessary,” said an Aetna spokesperson in an email. “In our outreach to the ophthalmology community of clinicians, we explained our rationale and discussed this new policy.”
The American Academy of Ophthalmology’s Glasser believes that the new legislation could help ophthalmologists minimize the impact of insurer policies, like Aetna’s, on patient care and their practices.
For one, the electronic prior authorization process established by the bill could help prevent treatment delays and get patients quicker access to care.
Further, the act will ensure that prior authorization requests are reviewed by qualified medical personnel, Glasser said.
Having secured majority bipartisan support, the bill’s co-sponsors are now waiting for the House majority leader to allow a vote.
“It is my hope that the bill will be given floor time for a vote soon so that we can be one step closer to improving seniors’ access to care in a more timely fashion,” Buschon said.
Credit: Piotrekswat, Getty Images
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