Bipartisan Bill Aims to Reform MA Prior Authorization

by Peter Johnson

A bipartisan bill, which was recently introduced in the House of Representatives by Rep. Suzan DelBene (D-Wash.) and co-sponsored by Reps. Mike Kelly (R-Pa.), Ami Bera (D-Calif.) and Larry Bucshon (R-Ind.), would push health insurers to make "real-time" prior authorization determinations for Medicare Advantage (MA) beneficiaries.

According to DelBene's press release, the Improving Seniors' Timely Access to Care Act would "establish an electronic prior authorization process, require HHS to establish a process for 'real-time decisions' for items and services that are routinely approved, improve transparency by requiring MA plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials, [and] encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians."

DelBene's bill has been endorsed by dozens of provider groups, but payer groups have been silent on the measure.

Michael Lutz, a senior consultant at Avalere Health and a former MA executive at Independence Blue Cross, says some payers and providers are more prepared for prior authorization mandates than others, which has been the case for payer interoperability rules, another tech-oriented regulatory mandate.

"The impacts will be unique to each plan, not necessarily based on the size of the plan," says Lutz via email. "For example, plans that tightly manage care with expansive Prior Authorization required conditions and services will be more impacted than plans that have few or no prior authorization requirements. Conversely, if done well, the automation of the easier cases may allow plans to free up clinical resources to focus on the complex requests, thus resulting in operational improvements and allowing the clinicians to focus their skills on those cases that most benefit from them."

"Another impact will be to provider offices," he adds. "If they don't have an electronic medical record (EMR) system, are not proficient with its functionality, or don't have skilled office staff, this could add an additional burden to the provider office."

Still, Lutz suggests prior authorization changes could be a break-even proposition for health care organizations.

"The big impact will be on implementation costs or the costs of vendor contracts to handle the system build and management. Over time, there may be some balancing with cost savings if the process results in operational efficiencies," he explains.

From Health Plan Weekly