• In The Trenches

    Chipping Away at the Burdens of Prior Authorization

    With most Americans about to get an extra day off, I want to tell you briefly about the Academy’s most recent efforts to lighten your workload.

    Prior authorization form with pen, calculator and glasses on desk

    A couple of weeks ago, four members of Congress introduced the Improving Seniors’ Timely Access to Care Act (H.R. 3173), which would streamline and reduce prior authorization requirements in the Medicare Advantage program. The AAFP immediately endorsed the legislation as part of the Regulatory Relief Coalition, 14 specialist societies working as a bloc to reduce Medicare’s administrative complexity.

    When similar commonsense legislation was introduced in 2019, the bipartisan bill had 280 co-sponsors and was endorsed by hundreds of medical, health and patient-advocacy groups, including the Academy. Little wonder: Its authors prominently cited a 2018 audit by the HHS Office of the Inspector General indicating, among other damning findings, that 75% of Medicare Advantage prior authorization denials over a two-year span (about 216,000 a year) were overturned. During the same period, “independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers,” added the report.

    The bill did not reach the floor for a vote the last time around. I’m hopeful we’ll see better results during this session, especially because its passage would likely drive welcome and badly needed improvements to prior authorization in commercial insurance plans.

    Additionally, the legislation’s focus on Medicare Advantage plans would fill a gap in CMS rulemaking that we noted this past December.

    “By not standardizing prior authorization across all payers governed by CMS, this rule will not meaningfully reduce the administrative burdens with which family physicians are grappling,” the Academy said in a Dec. 23 letter to outgoing HHS and CMS leaders.

    That rule, “Reducing Provider and Patient Burden by Improving Prior Authorization Processes,” published Dec. 20 in the Federal Register, was finalized but, along with other HHS moves made late in the Trump administration, put on hold by the new White House, pending review.

    And the AAFP, again in tandem with other medical groups, was equally prompt in objecting last month to recent prior authorization expansions by CMS.

    “We continue to have serious concerns that beneficiaries will experience significant barriers to access to medically necessary procedures as a direct result of the calendar year 2021 policy,” said our letter to CMS Acting Administrator Elizabeth Richter. “We also worry that future expansions of prior authorization will unnecessarily delay access to care for even more beneficiaries and add administrative and cost burden for providers unless appropriate and transparent regulatory processes are established.”

    Also last week, the Academy voiced strong approval for the Safe Step Act. That legislation would reduce administrative burden by implementing transparency guidelines to prevent inappropriate use of step therapy in employer-sponsored health plans and create a clear process for patients and physicians to seek reasonable exceptions to step therapy.

    “The AAFP has long advocated that step therapy should not be mandatory for patients already on a working course of treatment and that generic medications should not require prior authorization,” we told the legislation’s sponsors, Sen. Lisa Murkowski, R-Alaska, and Rep. Raul Ruiz, M.D., D-Calif. “Ongoing care should continue while prior authorization approvals or step therapy overrides are obtained. To ensure access,
    patients should not be required to repeat or retry step therapy.”

    Finally, Academy member Kisha Davis, M.D., M.P.H., of Gaithersburg, Md., appeared last week before the Senate Finance Committee to deliver detailed counsel on improving telehealth and ensuring health equity in virtual care — advice that included stern words about prior authorization.

    Among the dozen recommendations the AAFP outlined for lawmakers, we told senators in our written testimony:

    Medicare and Medicaid both waived prior authorization requirements for durable medical equipment and other services early on during the public health emergency. While these requirements have since been reinstated, Congress should permanently reduce the volume of prior authorization requirements across Medicare and Medicaid payers.

    It should indeed.

    NASEM Report Briefing

    The AAFP tomorrow evening co-hosts a national briefing on the comprehensive primary care report published this month by the National Academies of Sciences, Engineering and Medicine. The study — “Implementing High Quality Primary Care” — strengthens the case for primary care as the foundation of the U.S. health care system and makes policy recommendations that reinforce several of the AAFP’s long-standing advocacy positions.

    Our event, at 5:30 p.m. CT on May 26, includes two NASEM members and will be streamed on the AAFP’s Facebook channel. Watch this space for information on further events devoted to unpacking this important document.

    Stephanie Quinn is senior vice president of advocacy, practice advancement and policy.


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.