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ACR Supports Legislation to Improve Oversight and Transparency of Prior Authorization Use

The American College of Rheumatology (ACR) today applauded the introduction of the Improving Seniors' Timely Access to Care Act of 2019 (H.R. 3107), a bipartisan bill to protect patients enrolled in Medicare Advantage plans from prior authorization requirements that needlessly delay or deny access to medically necessary care.

The bipartisan legislation, which is sponsored by Representatives Suzan DelBene (D-WA), Mike Kelly (R-PA), Roger Marshall (R-KS), and Ami Bera (D-CA) would require the Centers for Medicare and Medicaid Services (CMS) to regulate the use of prior authorization by Medicare Advantage plans, including establishing a process to make ‘real-time decisions’ for services that are routinely approved. These plans would also be required to offer an electronic prior authorization process and report to CMS on how extensively they use prior authorization, as well as how often they approve or deny medications and services.

“For far too long, patients have faced unnecessary and unreasonable care delays due to insurers’ overzealous use of prior authorization,” said Paula Marchetta, MD, MBA, president of the ACR. “This practice creates significant burdens for physicians and can put patient’s health in jeopardy. We applaud Congressional leaders for standing up to ensure America’s Medicare beneficiaries are able to get the care they need and deserve.”

Prior authorization is a process used by many insurers, including Medicare Advantage plans, whereby a prescribing physician must obtain approval from the insurer before the patient can begin treatment. This is a time-consuming process that often involves a patient facing weeks-long delays before being able to start life-altering therapies. 

While originally intended to control costs by reducing unnecessary tests and procedures, many health plans are now indiscriminately using prior authorization, creating additional hurdles for patients and physicians that can lead to delays in treatment that may endanger patients’ health. The process for obtaining this approval can be lengthy and typically requires a physician or their staff to spend many hours each week negotiating with insurance companies – time that could be better spent taking care of patients. 

The ACR has been working to advance this legislation as part of the Regulatory Relief Coalition, a group of national physician specialty organizations advocating for a reduction in Medicare program regulatory burdens to protect patients’ timely access to care. 

This week, the Coalition released a national survey of 1602 physicians detailing the extent to which prior authorization places burdens on physicians and puts patients at risk. The survey found that 87 percent of physicians report that prior authorization has a significant (40 percent) or somewhat (47 percent) negative impact on patients’ clinical outcomes. Nearly a third of physicians surveyed said their patients often abandon treatment due to prior authorization. Furthermore, 84 percent of survey respondents said that the regulatory burdens associated with prior authorization has significantly increased over the past five years with half of all practices reporting 11 or more requests per week.

The author has no conflicts of interest to disclose related to this subject

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