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Bipartisan prior authorization legislation introduced

Jessie Hellmann, CQ-Roll Call on

Published in Political News

WASHINGTON — Two key lawmakers reintroduced a bill on Wednesday that would essentially codify parts of a Biden administration rule that aims to streamline the use of prior authorization in Medicare Advantage.

The bill, introduced by Sen. Roger Marshall, R-Kan., and Rep. Suzan DelBene, D-Wash., would require Medicare Advantage plans to establish electronic prior authorization programs for health care providers beginning in 2027.

Some Medicare Advantage plans still require health care providers to submit requests through fax machines or proprietary payer portals, which can result in increasing the burden on providers if different insurers use different prior authorization systems.

“Prior authorization is the number one administrative burden facing physicians today across all specialties,” Marshall said in a statement. “As a physician, I understand the frustration this arbitrary process is causing health care practices across the country and the headaches it creates for our nurses.”

Unlike the Centers for Medicare and Medicaid Services rule, which was finalized in January, Marshall’s and DelBene’s bill only applies to Medicare Advantage — not Medicaid or the Children’s Health Insurance Program.

It also would not address the timelines plans have to respond to prior authorization requests, but it would give the Health and Human Services secretary the authority to make those decisions.

The CMS rule would also require Medicare Advantage plans to include specific reasons for denying requests.

Marshall originally introduced similar legislation in 2021, but the bill hit roadblocks after the Congressional Budget Office gave it a $16 billion price tag.

Marshall’s office said since the Biden administration had finalized similar rules, the CBO reduced the cost of the bill, citing figures from the agency’s actuary that it would save physicians money because they would spend fewer hours on prior authorization tasks.

 

To further reduce the bill’s cost, the reintroduced bill made other changes as well, including removing language requiring that plans issue “real-time decisions” for commonly approved procedures.

The bill requires plans to submit information to the HHS secretary annually about which services require prior authorization, what share of requests are rejected and appealed, the average time it takes to respond to requests and other information.

The idea of changing prior authorization has become extremely popular in Congress, with major lobbying groups like the American Medical Association and American Hospital Association prioritizing it as one of their top issues.

Still, providers have been disappointed that the CMS rule doesn’t address the use of prior authorization for Part B drugs. Some lawmakers have expressed interest in that topic but haven’t introduced legislation. CMS officials said they would consider the issue in future rulemaking.

The House Ways and Means Committee advanced a bill last year that would require Medicare Advantage plans to issue “real-time” decisions for commonly approved services and report information about denials. Parts of that bill were absorbed into a separate bill that passed the House last year, but it did not include the prior authorization pieces, likely because of costs.

An earlier version of the bill also passed the House in 2022 under suspension of the rules, an expedited procedure that requires a two-thirds majority vote.

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