Improving Seniors Timely Access to Care
H.R. 3107, Care Act of 2019
CLA cosponsored legislation that streamlined and standardized the Prior Authorization (PA) process under Medicare Advantage (MA).
PA is a tool used by insurers to reduce spending from improper payments and unnecessary care by requiring physicians and other health care professionals to get pre-approval for medical services. But it’s not without fault. The current system of unconfirmed faxes of a patient’s medical information or phone calls by clinicians takes precious time away from delivering quality and timely care. PA continues to be the #1 administrative burden identified by providers groups and nearly four out of five MA enrollees are subject to unnecessary delays. In 2018, HHS’ Office of the Inspector General raised concerns after an audit revealed that MA plans overturned 75% of requests that were originally denied.
Health plans and providers agree that the process can be improved and agreed on principles in a consensus statement. Building on these principles, H.R. 3107 would streamline approvals by moving PA to an electronic process as well as identify items and services that are routinely approved – initially and on appeal – and adopt real-time decision making. Cost saving tools like PA are antiquated compared to innovative models like value-based arrangements (VBA). Until VBA can be widely adopted – provided there are changes in statute – stakeholders and the Trump administration agree to improve these cost saving tools and put patients over paperwork.
H.R. 3107 is supported by 400 organizations representing patients, providers, IT groups, and companies across the country. The Small Business Committee held a hearing on how PA negatively impacts small practice groups and submitted a letter to Ways and Means leadership in support of the bill.