Congress Advances Provisions to Fix Prior Authorization

The powerful House Ways and Means Committee has advanced provisions that would help bring badly needed reforms to the prior-authorization process within Medicare Advantage.

Among other critical steps, the Ways and Means-passed provisions would:

  • Require Medicare Advantage plans—through which over 30 million older adult Americans get care—to implement electronic prior authorization programs that adhere to new federal standards, as well as establish real-time decision-making processes for items and services that are routinely approved.

  • Enhance transparency by requiring Medicare Advantage plans to report to the Department of Health and Human Services (HHS) 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 disclose to physicians and beneficiaries the services requiring approval and the underlying policies and criteria.

  • Permit Medicare Advantage plans to institute gold-carding provisions.

  • Mandate that Medicare Advantage plans issue accelerated prior authorization decisions for all services in Medicare Part C.

The House Ways and Means Committee passage comes on the heels of a bipartisan, bicameral letter to HHS and the Centers for Medicare & Medicaid Services (CMS) urging CMS to finalize a pending federal regulation that would overhaul prior-authorization requirements within Medicare Advantage.