Medicare Advantage (MA) plans are able to require providers to obtain prior authorization for certain medical treatments or tests—including physical therapy care—before they can provide care to their patients. As evidenced by two reports from the Department of Health & Human Services’ (HHS) Office of the Inspector General (OIG)—in 2018 and one this past spring—it is not uncommon for therapists to follow all required guidelines from the MA plan and still receive rejections.
These findings bolstered support for the bipartisan Improving Seniors’ Timely Access to Care Act (S.3018/H.R.3173) because the bill will require MA plans to establish a transparent electronic prior authorization program that includes real-time decisions in response to requests for items and services that are routinely approved. MA plans will also be required to publish data annually on their use of prior authorization, including the average response time as well as the percentage of approved and denied requests.
The House of Representatives resoundingly passed the bill on September 14th. However, enactment of the bill is not guaranteed. The Congressional Budget Office (CBO) predicts that the use of prior authorization will decrease if the bill becomes law and therefore more services will be used. As a result of more care being provided, CBO expects MA plans to demand higher payments from the federal government to cover the cost of these additional services. CBO estimates the impact of the bill would cost the federal government $16.245 billion over 10 years.
While this high cost will make it harder to proceed, there is still incredibly strong support for the policy among lawmakers, the Administration and stakeholders. Over 450 organizations and companies are publicly supporting the legislation because the use of prior authorization frequently results in administrative burdens for providers, diverts precious time away from patient care, and delays approval for necessary services.
If this bill would remove obstacles for your patients and reduce the administrative burden you experience when navigating MA plans’ prior authorization protocols, reach out to your Senators and ask them to cosponsor and pass the Improving Seniors’ Timely Access to Care Act (S.3018/H.R.3173).