A bill in the US House of Representatives is designed to improve the prior authorization process and ensure timely access to care in Medicare Advantage, the corporate health insurer-administered arm of Medicare. Right now, doctors, hospitals and patients are stuck with a prior authorization system that is different for each Medicare Advantage plan and can create hurdles that waste a lot of time, deny people needed care and keep physicians from getting paid for their services. Under the prior authorization system, people die needlessly awaiting approval for critical care.
What exactly is prior authorization and why are corporate health plans, including Medicare Advantage plans, allowed to use it? Prior authorization is a system insurers create to oversee the care treating physicians prescribe. It is intended, at least in theory, to protect people from overtreatment and mistreatment.
But, prior authorization assumes that the folks at an insurance company know better the care patients need than their treating physicians. And, there is little basis for believing that in the overwhelming majority of instances. What’s worse is that insurers can and do appear to use prior authorization as a tool for maximizing their profits, limiting the amount they spend on care and, often, delaying if not denying needed care.
Hospitals and physicians have come together to oppose the way prior authorization works, both procedurally and substantively. They have polled their members to establish that prior authorization too often causes injury to patients if not needless death, is burdensome on them and rules are often out of sync with standard medical practice. For this reason, members of Congress on both sides of the aisle say they want to improve prior authorization.
Indeed, the bipartisan House legislation, Seniors’ Timely Access to Care Act, is quite comprehensive, focused on both the process for securing prior authorization and the services for which it is required. It has more than 300 cosponsors. But, the bill still permits each Medicare Advantage plan to set its own rules for when to require prior authorization and establishes no penalty for MA plans that do not comply with the law. It lacks any teeth.
If the bill were to become law and Medicare Advantage plans were to comply with its provisions, each Medicare Advantage plan would establish an electronic system for providers to seek prior authorization, saving them a lot of time and energy. Of course, the better law would require the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, to design the electronic system that everyone used so that it was standardized across all plans and any glitches were transparent and easily fixed. But, for reasons that are unclear, that simple solution is not on the table.
Here’s more from Just Care:
- OIG finds widespread inappropriate care denials in Medicare Advantage
- Well-kept secrets of Medicare Advantage plans
- Four things to think about when choosing between traditional Medicare and Medicare Advantage plans
- Roundup: 2022 Medicare benefits and more
- Government asks public how to improve Medicare Advantage
Leave a Reply