APTA-supported bipartisan legislation taking aim at misuse of prior authorization in Medicare Advantage plans has arrived at the U.S. House of Representatives. If signed into law, the bill could mark a major shift in Medicare Advantage by holding plans more accountable for their use of prior authorization, establishing a pathway for “real time” coverage decisions, and requiring MA companies to get more input from providers and other stakeholders on what is and isn’t deemed clinically appropriate

Known as the “Improving Seniors’ Timely Access to Care Act” (H.R. 3173) the bill now in the house wouldn’t completely eliminate the use of prior authorization but would move Medicare Advantage toward a more transparent and less burdensome process — a longtime policy goal for APTA. Reps Suzan DelBene, D-Wash, Mike Kelly, R-Penn, Ami Bera, D-Calif, and Larry Bucshon, R-Ind, introduced the bill, APTA explains.


The legislation is intended to put up guardrails around MA’s prior-authorization practices. According to a press release, the changes are necessary to improve a system that when misused “can result in administrative burdens for providers, taking previous time away from patient care and delaying needed medical intervention.”

Specifically, the bill would establish an electronic prior authorization process, require the implementation of a “real-time” decision system for items and services that are routinely approved, mandate that MA plans provide more detailed reports on use of prior authorization to the US Centers for Medicare & Medicaid Services (including their rates of approvals, denials, and average time for approvals), and press MA providers to do a better job of incorporating input from health care providers in their authorization programs and decisions.

The legislation is a good first step that’s in line with APTA’s 2021-2022 public policy priorities, according to David Scala , APTA senior specialist of congressional affairs.

“Prior authorization is receiving increased scrutiny from legislators and policymakers for good reason — because while it may be necessary in some form, when it’s misapplied or shaped by misinformed decisions about care, patients can be put at risk. This legislation is an acknowledgement that administrative burden associated with prior authorization ultimately affects patients. APTA applauds House members DelBene, Kelly, Bera, and Bucshon for their work to introduce this bill.”

APTA government affairs staff will monitor the progress of this legislation and provide updates and opportunities to help therapists make their voices heard as they arise. For more information on APTA’s advocacy efforts on Capitol Hill, visit the APTA Advocacy Network.

[Source: APTA]

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