A bill that will reform prior authorization for Medicare managed care plans has unanimously passed out of the U.S. House of Representatives on a voice vote. The legislation – the Improving Seniors’ Timely Access to Care Act of 2022 (HR 3173) – provides comprehensive reform of the Medicare Advantage prior authorization process by streamlining the health plan bureaucracy to help Medicare patients get the care they need – when they need it.

The California Medical Association (CMA) strongly supports this bill and is working  to pass the bill before Congress adjourns in December. CMA thanks the California Members of Congress for moving the bill and we urge the Senate to act swiftly to get it across the finish line.

“CMA applauds the bipartisan support for this important legislation, which will ensure that quality patient care remains the top priority – not the corporate bottom line,” says CMA President Robert E. Wailes, M.D. “Insurance company prior authorization red tape undermines health care outcomes by placing unnecessary obstacles to patients getting the care they need, when they need it.”

Prior authorization requirements can be challenging for patients, creating barriers to care and increasing administrative burdens for physicians who must spend time and resources to get approvals as insurance companies design and administer increasingly complex prior authorization systems.

Surveys of physicians have consistently found that excessive authorization controls required by health insurers are persistently responsible for serious harm when necessary medical care is delayed, denied or disrupted in an attempt to increase health insurer profits. In a 2021 AMA survey, 93% of physicians reported care delays due to unnecessary prior authorization requirements. Specifically, 90% of physicians said that prior authorizations had a negative impact on patient clinical outcomes with 34% of physicians reporting that prior authorization led to a serious adverse event for a patient in their care such as hospitalization, medical intervention to prevent permanent impairment, or even disability or death. Moreover, physicians and their staff spend nearly two days per week on administratively burdensome prior authorizations instead of spending more time with patients.

A recent U.S. Department of Health and Human Services-Office of Inspector General report found that every year Medicare Advantage plans inappropriately deny necessary care for tens of thousands of patients. 

HR 3173 will streamline Medicare Advantage prior authorization for routinely-approved services, ensure plans adhere to evidence-based guidelines developed by physicians, mandate public reporting of prior authorization decisions and timeframes, and implement an electronic process to reduce physician administrative burdens.