A group of bipartisan lawmakers this week reintroduced legislation aimed at curtailing restrictive – and often flawed – prior-authorization processes within Medicare Advantage (MA).
As it has been to most other parts of health care, prior authorization has long been problematic for home health providers and patients. That’s been increasingly true as more insurers have started to adopt systems and processes that use predictive analytics and algorithms to guide their decision-making, too.
In the Senate, the legislation – the Improving Seniors’ Timely Access to Care Act – was introduced by Sens. Kyrsten Sinema (I-Ariz.), Roger Marshall (R-Kan.), Sherrod Brown (D-Ohio) and John Thune (R-S.D.). Companion legislation was likewise put forth in the House, led by U.S. Reps. Mike Kelly (R-Penn.), Suzan DelBene (D-Wash.), Larry Bucshon (R-Ind.) and Ami Bera (D-Calif.).
“Right now, too many older Americans enrolled in Medicare Advantage are forced to deal with unnecessary delays when seeking out [care],” Sen. Brown said in a statement. “We need to update the Medicare Advantage program so it works better, faster, and is more transparent for patients and providers.”
If passed, the Improving Seniors’ Timely Access to Care Act would increase transparency around MA prior-authorization requirements and their use. It would additionally establish an e-PA process for MA plans, including a standardization for transactions and clinical attachments.
By digitizing parts of prior authorization, the hope is that some decisions could be reached faster – even in real time.
The Alzheimer’s Association, AARP, the American Hospital Association, the American Academy of Hospice and Palliative Care, and LeadingAge are among the many health and senior care groups to support the legislation.
“By removing unnecessary barriers that create delays in treatment, this meaningful bill will improve access to care for seniors and allow caregivers to spend more valuable time at the bedside with patients and less time on burdensome paperwork,” American Hospital Association Executive Vice President Stacey Hughes said in a statement
A flawed process
Broadly, prior authorization is designed to help health plans determine the medical necessity of services and minimize unnecessary services. In turn, that allows them to better contain costs and protect patients from receiving unnecessary care.
Between 2009 and 2019, the use of prior authorizations by MA plans increased substantially, previous research has found.
The process normally kicks off when a provider submits to an MA plan a request for prior authorization of services, which could include home health care services, home medical equipment (HME) and several other categories of services.
From there, the MA must decide as quickly as possible whether those services are appropriate. Plans have 14 days after receiving a standard request and 72 hours after receiving an expedited request.
Studies, government-watchdog investigations and U.S. Centers for Medicare & Medicaid Services (CMS) audits have suggested plans frequently get their prior-authorization decisions wrong.
The Medicare Payment Advisory Commission (MedPAC) highlighted the issue in its most recent report to Congress, in fact.
“Although only a small share of prior authorization requests are denied, CMS audits suggest that many denied requests should actually have been approved,” MedPAC wrote in the report. “The Office of Inspector General (OIG) found that CMS cited about half of audited MA contracts in 2015 for inappropriately denying prior authorization requests, for sending insufficient denial letters, and for missing required information such as why the request was denied or how to appeal.”
In 2021, the vast majority of MA prior-authorization reconsiderations were fully approved.
In a sample of 229,000 MA prior-authorization reconsiderations that year, 80% were returned fully favorable. Just 18% were upheld as adverse decisions, with 1% partially favorable.
“Prior authorization has been identified as a major source of administrative burden for providers and can become a health risk for patients if policies affect the treatments clinicians offer (e.g., step therapy requirements), inefficiencies in the process cause needed care to be delayed or abandoned, or poor decisions cause necessary care to be denied,” the MedPAC report continued.
For a health care provider or business, this back-and-forth can have a profoundly negative impact.
“For the past year to two years, we went from a manageable amount of prior authorizations or denials to an absurd amount of denials right off the bat … ,” one physician said in a 2023 focus group, with MedPAC noting this comment in its report. “We’ve had to hire staff just to deal with [authorizations] and denials.”
Home health and prior authorizations
Over the past two years, multiple MA plans have begun to shed prior-authorizations requirements for home health care, in particular.
In August 2023, for example, The Cigna Group (NYSE: CI) announced that it was removing nearly 25% of medical services from its prior authorization requirements.
In November of last year, Blue Cross Blue Shield of Massachusetts announced it was eliminating prior authorization for home health care.
“We know from our clinical partners that local hospitals are experiencing a capacity crunch – we’re doing what we can to help,” BCBS of Massachusetts Chief Medical Officer Dr. Sandhya Rao told Home Health Care News at the time. “By removing prior authorization requirements for home care services, we’ll help hospitals to expedite discharges at a time when many are struggling with overcrowding.
Additionally, this past April, Point32Health announced that it is removing prior-authorization requirements for the first 30 days of home health care.
“We continuously evaluate all our programs to ensure our members are receiving the highest quality of care and work closely with our provider partners to decrease their administrative burden wherever possible,” Dr. Hemant Hora, senior medical director at Point32Health, previously told HHCN.
