The Seniors’ Timely Access to Care Act, which requires insurance companies to promptly approve routine care requests and respond within 24 hours to urgent requests, was reintroduced in the House this year. It was also passed by the House Ways and Means Committee in the summer as a part of a larger healthcare package.

However, legislators are bombarding the Biden administration with requests to revamp the frequently employed method known as prior authorization. This is the procedure in which health insurance companies require patients to obtain approval from the insurer beforehand for specific treatments or medications.

According to Representative, the current situation involves preventing individuals from receiving necessary care, rather than facilitating the process.Pramila Jayapal

Rep. (D-Wash.) is the head of the House Progressive Caucus.

Increased twofold over the past ten years.

But Sen. James Lankford

Representative from Oklahoma (R-Okla.) stated that certain hospitals in his state are no longer accepting Medicare Advantage plans due to the financial burden of constantly appealing denials.

According to AHIP, the organization that represents insurance companies, prior authorization is one way to reduce unnecessary expenses.

According to spokesperson David Allen, these resources play a crucial role in managing healthcare, minimizing unnecessary and low-quality services, and making healthcare more affordable for patients and consumers.

Legislators claimed it was fraudulent..

For the first time this year, it is assessing Medicare Advantage commercials before they are broadcast, due to pressure from legislators and numerous grievances from older individuals who felt misled by the widespread advertisements.

The CMS has put forth a suggestion that plans must consider the influence of prior authorization denials on disadvantaged and underserved populations. This is part of a broader initiative by the agency to address disparities in health equity. If the rule is approved, it will go into effect in 2025.

Sen. Elizabeth Warren (D-Mass.), who wants the agency to go further, has proposed an amendment that would require CMS to collect and publish data from Medicare Advantage plans on their prior authorization practices to make public the number of prior authorization requests, denials and appeals by type of medical care.

The Senator is providing her with support.Mike Crapo

Senator R from Idaho expressed his support for Medicare Advantage plans during a recent hearing, but also acknowledged that he has concerns about the prior authorization process and believes that improvements need to be made.

The Better Medicare Alliance, an advocacy group for insurers, stated to POLITICO that they are in favor of implementing laws and rules that would establish an electronic method for prior authorization. This new process could speed up the usually lengthy prior authorization decision-making process, which can take up to a week or longer.

“We have consistently aimed to safeguard the critical role of prior authorization in ensuring safe, efficient, and valuable healthcare for patients. At the same time, we are working to enhance and simplify this clinical tool in order to better benefit beneficiaries,” stated Mary Beth Donahue, president and CEO of the organization.

In a recent survey conducted by the Medical Group Management Association, it was discovered that 97% of medical group practices experienced delays or denials from insurers for medically necessary care. Additionally, 92% of these practices reported hiring staff specifically to handle prior authorization requests. Another survey conducted by the American Medical Association in December 2022 revealed that 94% of physicians faced delays in providing care due to prior authorization denials or processing.

According to Vivek Kavadi, the chief radiation oncology officer for U.S. Oncology, regardless of the cost-effective treatment you choose, you will have to go through the prior authorization process. U.S. Oncology is a network of over 1,200 physicians.

Research indicates that the field of oncology receives the highest number of prior approval requests.

Five cancer doctors informed POLITICO that there has been a rise in prior authorization requests as more individuals switch from regular Medicare to Medicare Advantage. According to them, this sudden increase in requests from insurance companies has placed a burden on their practices’ available resources.

In 2020, a survey conducted by the American Society for Radiation Oncology (ASTRO) revealed that 64% of oncologists experienced an increase in treatment delays caused by prior authorization requests during the pandemic.

Insurers may at times contract with radiation benefit managers, companies that manage claims processing and keep a cut of savings they generate. This can encourage more services requiring prior authorization and create a “greater incentive to identify opportunities where denials can be pushed on to the provider,” said Constantine Mantz, chief policy officer for the oncology network GenesisCare.

According to EviCore, a company that manages radiation benefits, their goal is to promptly provide patients with care based on the most current clinical research. In cases where requests do not align with evidence-based guidelines, physicians have the chance to have a conversation about the situation and potentially address any issues before starting a formal appeal. The company released a statement explaining this process.

BMA chose not to provide a statement, while AHIP refused to answer a series of inquiries regarding radiation benefit managers.

According to Mantz, Medicare Advantage plans have been sluggish in adjusting their coverage policies, sometimes falling behind traditional Medicare in terms of which treatments are included. As a result, there may be cases where a Medicare Advantage plan denies treatment that would have been approved under traditional Medicare after a prior authorization request was made.

A report published in 2022 discovered that 13% of claims from Medicare Advantage plans were denied for services that should have been approved under prior authorization. The Office of Inspector General (OIG) found several instances where advanced imaging services and stays at inpatient rehabilitation facilities were denied due to prior authorization.

In case of a denied request, a doctor has the option to file an appeal and ultimately consult with another physician to present their argument.

New research has revealed that the majority of rejections are reversed upon appeal. According to a study by KFF, in 2021, Medicare Advantage plans rejected over 2 million claims through prior authorization, but 82 percent of those were ultimately overturned upon appeal. A survey by ASTRO in 2019 also showed that 62 percent of oncologists successfully overturned prior authorization denials when advocating for their patients.

However, physicians claim that navigating the appeals procedure can be a lengthy process, often lasting several weeks.

Amar Rewari, the chief of radiation oncology for Luminis Health in Maryland, believes that the business model may be designed by insurance companies to save money by discouraging physicians from participating in the peer-to-peer process, as it can be time-consuming.