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Reduce Prior Auth Burdens in Medicare Advantage

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The prior authorization approval process, now more than ever, consumes valuable physician and staff time, costs physician practices money, and may negatively impact patients by delaying much-needed treatment. Research shows that the national time-cost of prior authorization is at least $23 billion annually.

Medicare Advantage
One in every three people with Medicare is enrolled in a Medicare Advantage (MA) plan. Under current law, MA plans may not create inappropriate barriers to care that do not already exist within the original Medicare program. However, physicians are reporting that MA plans have imposed increasingly onerous prior authorization requirements for medical services and procedures that are impacting patient access to medically necessary care. AGA and other physician organizations are advocating for regulatory changes related to how MA plans use prior authorization. 

The Improving Seniors Timely Access to Care Act (H.R. 3173/S. 3018), which was introduced by Reps. Suzan DelBene, D-WA, Mike Kelly, R-PA, Ami Bera, MD, D-CA, and Larry Bucshon, MD, R-IN, in the House and by Sens. Roger Marshall, MD, R-KS, Krysten Sinema, D-AZ, and John Thune, R-SD, in the Senate, is legislation that aims to increase transparency and streamline the prior authorization process in the Medicare Advantage program by:

  • Establishing an electronic prior authorization (ePA) program and require MA plans to adopt ePA capabilities;
  • Requiring the Secretary of Health and Human Services to establish a list of items and services eligible for real-time decisions under an MA ePA program;
  • Standardizing and streamlining the prior authorization process for routinely approved items and services;
  • Ensuring prior authorization requests are reviewed by qualified medical personnel;
  • Increasing transparency around MA prior authorization requirements and their use; and
  • Protecting beneficiaries from any disruptions in care due to prior authorization requirements as they transition between MA plans.
Urge your member of Congress to cosponsor H.R. 3173/ S. 3018 today!

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