Nearly 300 members of Congress signed a bipartisan letter urging the Centers for Medicare and Medicaid Services (CMS) to finalize a proposed rule that would streamline prior authorization protocols for federally sponsored health insurance programs, including Medicare Advantage plans, and ensure seniors have timely access to care.
The letter asked CMS to “promptly finalize and implement” proposed rules supported by the California Medical Association (CMA) that would increase transparency and improve the prior authorization process for patients and physicians through the following provisions:
Provide incentives for payers to adopt a “gold-carding” or TSA pre-clearance type of program that exempts physicians with a history of high prior authorization approval rates.
Mandate appropriate clinical evidence to back up payor prior authorization decisions regarding medical necessity and the clinical criteria must be publicly available to physicians.
Require plans to establish a Utilization Management Committee with physicians.
Increase public transparency of payor approvals, denials, and overturned decisions, as well as response times.
Require payors to establish a uniform electronic prior authorization system.
Establish deadlines for prior authorization decisions. CMA is urging shorter deadlines (24 hours for expedited requests/48 hours for standard requests) to prevent adverse outcomes.
Require payors to provide reasons for denials and restrict retroactive denials, which essentially mandates payment for all approved services.
Members of Congress also asked CMS to expand on the proposed rules by adding the following provisions:
Establish a mechanism for real-time prior authorization for routinely approved items and services.
Require that plans respond to prior authorization requests within 24 hours for urgently needed care.
Require detailed transparency metrics.
The letter was led by Suzan DelBene (D-WA) and California’s physician Congressman Ami Bera (D-CA) and signed by a bipartisan group of 233 representatives and 61 senators. CMA garnered support from a vast majority of the California Congressional Delegation who signed the letter.