Dateline DC—Congress proposes transparency and oversight of prior authorization

Utilization review tools such as prior authorization (PA) can sometimes play a role in ensuring patients receive clinically appropriate treatment while controlling costs. However, the American College of Surgeons (ACS) is concerned about the growing administrative burdens and the delays in medically necessary care associated with excessive PA requirements. Surgical patients are encountering barriers to timely access to care because of onerous and unnecessary PA requests from Medicare Advantage (MA) plans.

A 2017 ACS survey of nearly 300 surgeons and practice managers indicated that, on average, surgical practices receive approximately 37 PA requests per physician per week, taking physicians and staff 25 hours—the equivalent of three business days—to complete. The exorbitant amount of time and resources practices must devote to PA largely is a result of a lack of automated PA processes that integrate with electronic health records (EHR) and other digital practice management systems.

Furthermore, some MA plans are not applying PA in a meaningful way for patients. Many PA requirements are applied to items or services ordered in accordance with an already approved plan of care; as part of appropriate, ongoing therapy for chronic conditions; or for items or services with low PA denial rates. The ACS maintains that PA requirements should be restricted to complex cases or to clinicians who have ordering patterns that differ substantially from other practitioners after adjusting for patient population.

Legislative efforts

The ACS has joined with the Regulatory Relief Coalition, a collective of specialty physician organizations, to work with key members of Congress to develop bipartisan legislation that would improve the transparency and efficiency of the PA process in the MA program.

As part of this collaboration, last year the ACS participated in an effort to gain support for a congressional sign-on letter to the Centers for Medicare & Medicaid Services (CMS) requesting that the agency provide guidance to MA plans regarding the use of prior authorization. More than 100 members of Congress signed on to this ACS-supported bipartisan letter, demonstrating  that members of Congress are concerned that overuse of prior authorization could result in significant barriers to timely, medically appropriate care. As part of this year’s Leadership & Advocacy Summit (LAS), the ACS convened a panel on the issues associated with PA. Panelists highlighted the burdens physicians are facing, the Capitol Hill perspective, and what CMS is doing to address these issues. To follow up on the concerns addressed in the panel discussion, 292 LAS attendees went to Capitol Hill to discuss the importance of addressing the inappropriate application of prior authorization by MA plans. These efforts, in conjunction with supplemental grassroots activities that include a legislative call-to-action available via SurgeonsVoice and additional opportunities for surgeon advocates to continue to educate their members of Congress at home, led to the introduction of legislation.

In June, Reps. Suzan Delbene (D-WA); Mike Kelly (R-PA); Roger Marshall, MD (R-KS); and Ami Bera, MD (D-CA), introduced the Improving Seniors’ Timely Access to Care Act, H.R. 3107. This ACS-supported legislation is a critical step toward improving the transparency and efficiency of the PA process in the MA program.

H.R. 3107 would improve the PA system by requiring CMS to regulate MA plan use of PA. The ACS is particularly appreciative of a provision in the bill that would prohibit MA plans from requiring PA for any surgical or other invasive procedure if the procedure is furnished during the peroperative period of a procedure that already was approved or did not require PA.

Whereas the legislation includes some beneficiary protection standards to ensure continuity of care, the ACS anticipates that this bill will serve as a stepping stone for further patient protections and standardization of PA requirements and processes. Because of the lack of standardization among MA plan PA processes, the ACS believes that the inclusion of electronic transmission and transaction standards as a step in the right direction. The inclusion of these electronic standards will help to facilitate real-time decisions for those services that are routinely approved.

In addition, H.R. 3107 will bring greater transparency to the PA process by requiring MA plans to report to CMS on the extent of their PA use and the rate of approvals or denials by service and/or prescription medication. By bringing transparency to MA plans’ use of prior authorization and reducing unnecessary requests, this legislation will help to ensure timely and medically necessary patient care.

An alert to encourage your Representative to take action is available. To learn more about congressional action on this bill, contact Carrie Zlatos, ACS Senior Congressional Lobbyist, at czlatos@facs.org.

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