Congress Urges CMS to Finalize Pending Regulation for Medicare Advantage

July 28, 2023
Once passed, the proposed rule will target pre-authorization requirements within MA.

The Centers for Medicare & Medicaid Services (CMS) is under pressure from lawmakers in Congress to finalize a proposed federal regulation that is intended to improve the current pre-authorization process required with Medicare Advantage. A recent letter sent to CMS about the issues involved cites cost, inefficiency, and patient care delays as areas that need improvement. The letter was signed by 61 senators and 233 House members, and received support from the American Medical Association (AMA).

Within the letter, the lawmakers wrote, “We urge CMS to promptly finalize and implement these changes to increase transparency and improve the prior-authorization process for patients, providers and health plans. We are pleased that these proposed rules align with the bipartisan, bicameral Improving Seniors’ Timely Access to Care Act, which proposes a balanced approach to prior authorization in the [Medicare Advantage] program that would remove barriers to patients’ timely access to care and allow providers to spend more time treating patients and less time on paperwork.” 

Lawmakers also urged CMS to expand on the proposed rule by:

·      Establishing a mechanism for real-time electronic prior authorization decisions for routinely approved items and services.

·       Requiring that plans respond to prior-authorization requests within 24 hours for urgently needed care.

·       Requiring detailed transparency metrics. 

These concepts were addressed in a proposed prior-authorization rule released by CMS last December, with the recent letter from Congress serving as an additional push to include the policies in the final regulation. According to the AMA, prior authorization is “overused, and existing processes present significant administrative and clinical concerns.” Among 1,001 physicians surveyed by the AMA in December, a majority of physicians reported that pre-authorization requirements “lead to unnecessary waste and avoidable patient harm.” One-third of respondents noted that prior authorization led to a serious adverse event for a patient in their care. 

Within the survey, physicians reported that prior authorization led to:

·       A patient’s hospitalization—25%.

·       A life-threatening event or one that required intervention to prevent permanent impairment or damage—19%.

·       A patient’s disability or permanent bodily damage, congenital anomaly or birth defect, or death—9%. 

The AMA strongly supported the legislation for the Improving Seniors’ Timely Access to Care Act, which would help fix prior authorization within Medicare Advantage. The AMA also played a major role in securing enough co-sponsors to ensure the bill passed the House of Representatives last September.