Bill Would Streamline Medicare Advantage Prior Authorizations

As hospices ready themselves for a Medicare Advantage (MA) carve-in, U.S. Reps. Suzan DelBene (D-Wa.) and Mike Kelly (R-Pa.) plan to introduce a bill to reduce regulatory burdens associated with the prior authorization process, a legislative aide from DelBene’s office told Hospice News.

Though the bill text is not yet complete, the co-sponsors are basing the draft on language contained in the SUPPORT for Patients and Communities Act, which became law in Oct. 2018.

The SUPPORT Act required the U.S. Department of Health and Human Services (HHS) to provide for the secure electronic transmission of prior authorization requests from prescribers to the MA plans, using systems compliant with HHS technical standards.


“The electronic prior authorization process and standards [in the forthcoming legislation] must allow for the efficient transfer of clinical information for the purposes of facilitating an automatic decision,” Rep. DelBene’s aide told Hospice News. “The bill will also require plans to report to the [HHS] secretary what items are subject to prior authorization, the rate of approval, and the time average time for approval.”

Prior authorization is a cost-control procedure that requires health care organizations to obtain approval from a payor to provide a particular service or therapy. MA plans require prior authorization to see specialists, receive out-of-network care, receive non-emergency hospital care, and some other circumstances. Medicare Part D plans also require authorization before certain medications can be prescribed.

Traditional Medicare generally does not require prior authorizations, with some exceptions such as durable medical equipment and physician services.


Some hospice organizations expressed concern about prior authorizations.

“Prior authorization requirements are a serious threat under Medicare Advantage, and particularly with respect to highly vulnerable hospice patients,” Theresa Forster, vice president for Hospice Policy at National Association of Home Care & Hospice told Hospice News. “Prior authorization creates delays in services and imposes additional hoops that providers must jump through to ensure patients receive needed items and services. With patients who are terminally ill, these delays can, at times, prolong pain and hasten death.”

The forthcoming bill will also incorporate aspects of a consensus statement released by a group of health care industry organizations, including American Medical Association and the American Hospital Association, among others, according to DelBene’s office.

The consensus statement called for a redesign of the prior authorization process, in which some providers would be exempt based on performance on quality measures, adherence to evidence-based practices, or contractual agreements.

“[Such a system] can be helpful in targeting prior authorization requirements where they are needed most and reducing the administrative burden on health care providers,” according to the statement.

The organizations called for a regular review of the list of services or prescriptions for which prior authorization is required to identify therapies that no longer need the authorization due to low utilization or low denial rates.

The group recommended making such lists accessible via websites and annual communications from plans to health care providers.

“Effective, two-way communication channels between health plans, health care providers, and patients are necessary to ensure timely resolution of prior authorization requests to minimize care delays and clearly articulate prior authorization requirements, criteria, rationale, and program changes,” according to the consensus document.

Kelly and DelBene expect to introduce the bill at the start of the next legislative work period, before May 23.