Representative Suzan DelBene has heard too many baffling stories about pre-clearance.
A relative of one of his relatives was due to undergo surgery as COVID-19 cases plummeted and procedures started again, but had to cancel the operation due to lack of timely pre-clearance. In another scenario, a large insurer decided it needed pre-approval for cataract surgeries.
“There are so many stories we have heard. If you or your loved ones are frustrated with the healthcare system, it’s not just you. We know it’s people across the country and so many families,” said Rep. DelBene, a member of the House Ways and Means Committee and chair of the moderate New Democrat coalition.
DelBene, who represents Washington’s 1st congressional district, co-sponsored a bipartisan bill, the “An Act to improve rapid access to care for seniors– this would ease the pre-authorization challenges that physicians face in caring for patients covered by Medicare Advantage plans. She explained how during an episode of “AMA Moving Medicine.”
Fixing prior authorization is a critical part of the AMA’s stimulus package for American physicians. You took care of the nation. It’s time for the nation to take care of you. It’s time to rebuild. And WADA is ready.
Prior authorization is overused and existing processes present significant administrative and clinical challenges. Learn how the AMA is tackling prior authorization with research, practice, and reform resources.
More than a third (34%) of physicians responding to an AMA survey (PDF) reported that prior authorization had resulted in a serious adverse event in a patient.
“The more things are standardized, the more we can see streamlined prioritization, the more time providers spend delivering healthcare versus billing application forms,” DelBene said.
Legislation also presented to the Senate, reduces unnecessary delays in care by streamlining and standardizing pre-authorization under the Medicare Advantage program. The legislation, which has more than 330 bipartisan co-sponsors in the House and Senate, incorporates all key elements of a 2018 consensus statement developed by doctors, hospitals, medical groups, health plans and pharmacies.
Specifically, the bill:
- Require Medicare Advantage to plan to implement electronic prior authorization programs that meet newly developed federal standards and are able to integrate seamlessly into electronic health systems (vs. proprietary health plan portals) , as well as establishing real-time decision-making processes for regularly approved items and services.
- Mandate that plans report to the Centers for Medicare & Medicaid Services on the extent of their use of prior authorization and the rate of approvals and denials.
- Require plans to adopt transparent prior authorization programs that are reviewed annually, adhere to evidence-based guidelines, allow gold patenting, and include continuity of care for people transitioning from a coverage policy to another to minimize any interruption of care.
- Hold plans accountable for making timely prior authorization decisions and justifying denials.
“One of my priorities has been to make sure our policies have followed the way the world works today,” DelBene said.
Health systems use surprisingly outdated technologies such as fax machines to process prior authorization requests and exchange information, DelBene noted. There is an opportunity to update and standardize technology to make this process faster and more efficient, she pointed out.
“There’s no reason for something that gets approved on a regular basis to be delayed,” DelBene said.
Prior authorization hurts patients, doctors and employers. It’s time to #FixPriorAuth.
The hope is that the bill’s provisions could lead to broader changes in the private insurance market, where payers are investing more in modernizing prior authorization systems, she said.
The bill is expected to be annotated at the Ways and Means Committee later this month.
Doctors and patients can visit fixpriorauth.org for more information on the “Improved Access to Care for the Elderly Act”.
“AMA Moving Medicine” highlights innovation and emerging issues impacting physicians and public health today. You can see all the episodes by subscribing to the WADA’s YouTube channel or the audio-only podcast versionwhich also offers educational presentations and in-depth discussions.