The American Hospital Association said that commercial health insurers should be held accountable for ensuring appropriate access to care, including by reducing the “excessive use of prior authorization.” The group is also seeking to reduce administrative burdens that “take clinicians away from the bedside and contribute to burnout, such as excessive and unnecessary prior authorization use and inappropriate coverage denials that require substantive clerical rework by staff.”
The Medical Group Management Association is seeking to eliminate or significantly reduce the volume of prior authorizations and other prerequisites for coverage.
“There must be greater health plan transparency, uniform national standards, and increased automation in prior authorization,” the MGMA said. “Utilization review policies should never interfere with the delivery of medically necessary care.”
The American Medical Association and the Federation of American Hospitals are both urging Congress to pass the Improving Seniors’ Timely Access to Care Act, which aims to reform the Medicare Advantage prior authorization process. Among other things, the bill would establish an electronic prior authorization process for MA plans including a standardization for transactions and clinical attachments. It would also increase transparency around MA prior authorization requirements and their use.
The FAH said that although the group is a strong supporter of Medicare Advantage, the group is “increasingly concerned by the alarming practices of MA plans that harm patients by eroding access to and affordability of medically necessary care.”
“Getting this legislation across the finish line would reduce the burden and complexity of prior authorization requirements imposed by MA plans,” the group said.
At the state level, lawmakers in Indiana and Rhode Island have introduced prior authorization reform legislation.
The proposed legislation in Indiana would cap all prior authorization rates at 1%. It would also ban prior authorization on drugs under $100 and prohibit the use of step therapy protocols on certain drugs. It would also require that a physician within the same specialty issue a denial, rather than an algorithm or a physician with a different background.
Rhode Island’s proposed legislation would prohibit payers from imposing prior authorization requirements for any admission, item, service, treatment or procedure ordered by an in-network primary care provider.
Proposed prior authorization reform legislation is also likely to emerge soon in North Carolina, the News & Observer reported Jan. 25.
The CEOs of UnitedHealth Group and Cigna Group also addressed prior authorization on their most recent earnings calls.
UnitedHealth Group CEO Andrew Witty said the company is working to make coverage and costs easier to understand, including by investing in technology to speed up approvals for Medicare Advantage patients and reducing the number of prior authorizations it requires in MA.
Cigna CEO David Cordani said his company will invest in making prior authorization faster and simpler in 2025. He said efforts to ease prior authorization and improve access to care navigation for members with complex health conditions will “incur additional costs” but are “critical actions for the benefits of customers and patients.”
