Bill would allow physicians to make prior authorization judgments

Photo: John Baggaley/Getty Images

Lawmakers in the House of Representatives have rolled out a bipartisan bill that would task board-certified specialists with determining the medical need of prior authorization requests.

The Reducing Medically Unnecessary Delays in Care Act would reform the practice of prior authorization in Medicare and Medicare Advantage by requiring that board-certified physicians in the same specialty are the ones making those decisions.

It would also direct Medicare, Medicare Advantage and Medicare Part D plans to comply with requirements that restrictions must be based on medical necessity and written clinical criteria, as well as additional transparency obligations.

Congressman Dr. Mark Green, R-TN, sponsored the bill along with Doctor Caucus co-chair Rep. Dr. Greg Murphy, R-NC, and the Congressional Democratic Doctors Caucus co-chair Dr. Kim Schrier, D-WA.

The GOP Doctors Caucus is composed of medical providers who use their healthcare expertise and backgrounds to develop patient-centered health care policy.

WHAT’S THE IMPACT

The lawmakers said the bill would eliminate non-expert decision-makers from a patient’s care, especially in cases in which a physician had already deemed a particular service necessary. 

The bill also requires that Medicare, MA and Part D plans publish clinical criteria on their preauthorization standards on the web to show that they’re regularly updated and align with current care standards. 

Those standards, according to the bill, should be evidence-based if they are to be used as justification to deny coverage.

According to the American Medical Association, physicians and their staff spend an average of 16 hours a week on prior authorization paperwork – about two business days.

“As a survivor of both colon and thyroid cancer, I know how critical it is to start treatment as soon as possible,” said Green. “Prior authorization can be a roadblock that costs lives. Doctors need to be able to make fast, life-saving decisions without a jungle of red tape to cut through.”

The bill has been endorsed by several industry groups, including the American Medical Association, American Osteopathic Association, American College of Emergency Physicians, American College of Physicians and American Academy of Family Physicians.

“The overuse of prior authorization is a persistent obstacle that prevents patients from receiving quality care from their physicians,” said American Medical Association President Dr. Bruce A. Scott. “Often, prior authorization requests are reviewed – and denied – by insurance company representatives who lack the medical expertise to appropriately judge what level of care is necessary for a patient. This welcome legislation would require the reviewers to be physicians with actual experience in the field of medicine they are passing judgment over. Our patients deserve no less.”

THE LARGER TREND

Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023, reflecting steady increases over the past few years as the number of MA enrollees has grown, according to a January KFF analysis.

In 2023, there were nearly two prior authorization determinations on average per Medicare Advantage enrollee, similar to the amount in 2019. In contrast, in 2023, about one prior authorization review was submitted per 100 traditional Medicare beneficiaries – a rate of about 0.01 per person – which, according to KFF, reflects the limited set of services subject to prior authorization in traditional Medicare.

A June 2024 survey from the American Medical Association found the prior authorization process continues to have a “devastating” effect on patient outcomes, physician burnout and employee productivity.

In addition to negatively impacting care delivery and frustrating physicians, PA is also leading to unnecessary spending in the form of additional office visits, unanticipated hospital stays and patients regularly paying out-of-pocket for care, results showed.

In the AMA’s annual survey of 1,000 practicing physicians, 94% reported that PA resulted in delays to care, while 78% reported that it can sometimes lead to the abandonment of treatment altogether.

Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.