Legislation that cleared the House would require Medicare Advantage plans to establish electronic prior authorization processes and would create new reporting requirements around their use of prior authorization.
The House unanimously passed the Improving Seniors’ Timely Access to Care Act, which, in addition to requiring an electronic process, would require MA plans to report to CMS on their use of PA and their rates of approvals and denials.1 Meanwhile, HHS would need to provide a process for rapid decisions on equipment and care that are routinely approved.
The bill now goes to the Senate, where bill sponsor Rep. Suzan DelBene, D-Wash., says it “has strong bipartisan support.”1
Prior authorization can improve health care and lower costs by preventing unsafe or ineffective care.2 While some stakeholders have raised concerns that it is burdensome, especially under a manual, paper-based system, MA plans have already been working toward improving prior authorization.2 This includes the AHIP-led Fast PATH initiative, launched in 2020 to assess the impact of electronic PA.3
The results of the study were recently published in the Journal of the American Pharmacists Association, and findings indicate electronic PA is associated with:
- fewer phone calls and faxes
- a better understanding of PA processes
- faster time to decisions
- faster time to patient care.
Providers used electronic PA tools for about 62% of PAs over six months and saw the median time from PA request to decision drop from 18.7 hours to 5.7 hours.4 Reduced time to decision was the primary benefit, but there may be other benefits seen with greater adoption, the authors note.
Physicians have so far been slow to adopt electronic health data exchange, including electronic PA. In 2019 about 35% of office-based physicians used only fax, email or e-fax to share patient health information with providers outside their organization.2
As MA plans continue optimizing their processes, the industry’s proactive approach in moving toward e-PA will benefit all stakeholders and, most importantly, will connect members with the most effective care as quickly as possible.
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- Cass, A. House passes prior authorization reform bill: 4 things to know. Becker’s Payer Issus. Sept. 15, 2022 https://www.beckerspayer.com/payer/house-passes-prior-authorization-reform-bill-4-things-to-know.html
- How health insurance providers are delivering on their commitments. AHIP. July 27, 2022. https://www.ahip.org/resources/how-health-insurance-providers-are-delivering-on-their-commitments
- Peer-reviewed JAPhA article highlights results Fast PATH initiative to improve prior authorization. AHIP. Aug. 17, 2022. https://www.ahip.org/news/articles/peer-reviewed-japha-article-highlights-results-fast-path-initiative-to-improve-prior-authorization
- Clayton, D., Bravo-Taylor, E., Bundy, K., et al. Evaluation of the Fast Prior Authorization Technology Highway. JAPhA. Aug. 9, 2022. https://www.sciencedirect.com/science/article/abs/pii/S1544319122002394