Congress Introduces Legislation to address Prior Authorization Challenges

On June 12, the Improving Seniors’ Timely Access to Care Act (H.R.8702/S.4518) was officially reintroduced in both the House and Senate. The bill, which aims to streamline the prior authorization process for items and services under Medicare Advantage, has strong bipartisan support with 125 original sponsors in the House and 42 original sponsors in the Senate.

The bill unanimously passed the House in the 117th Congress but faced challenges due to its $16 billion Congressional Budget Office (CBO) score. In the interim, the Centers for Medicare & Medicaid Services (CMS) finalized its Interoperability and Prior Authorization rule. With these policies in place, the legislation was revised, and the CBO score was reduced to zero. The recently reintroduced legislation further streamlines the prior authorization process under Medicare Advantage.

Specifically, the bill would do the following:

• Establish an electronic prior authorization (e-PA) process for MA plans including a standardization for transactions and clinical attachments.
• Increase transparency around MA prior authorization requirements and their use.
• Clarify CMS’ authority to establish timeframes for e-PA requests including expedited determinations, real-time decisions for routinely approved items and services, and other PA requests.
• Expand beneficiary protections to improve enrollee experiences and outcomes.
• Require the Department of Health and Human Services and other agencies to report to Congress on program integrity efforts and other ways to further improve the e-PA process.

SGO members report that the PA process is one of the leading causes of frustration and burnout among physicians and their staff. As members know, gynecologic cancers are often aggressive and fast spreading, and timely access to care is key to achieving better outcomes. Delays in care caused by the lack of a prior authorization or a delay in receiving a prior authorization causes undo emotional and potentially physical harm to the patient.

For these reasons, SGO has been a proud supporter of this legislation for many years, and we are pleased to have joined over 370 national and state organizations in supporting this bipartisan, bicameral legislation in the 118th Congress. We hope to see the legislation cross the finish line and enacted into law before the end of this year.