Prior-authorization reform gains traction

Prior-authorization reform gains traction

Sen. Marshall

Though efforts to reduce the burden of prior authorization didn’t advance in the Kansas Legislature this year, there is hope for reform at the federal level.

U.S. Sen. Roger Marshall, MD, who will be speaking at an MSSC membership meeting on Aug. 22, is leading a bipartisan effort to improve the Medicare Advantage prior-authorization process. At a Senate hearing in May, Marshall complained that prior authorization has “become a tool to delay care — hoping the patient dies so they don’t have to give any more care, I guess.”

An audit revealed that Medicare Advantage plans ultimately approved 75% of requests that were originally denied. Another report found that MA plans requested unnecessary documentation, made manual review efforts and system errors, and used clinical criteria that are not contained in Medicare coverage rules.

The Improving Seniors’ Timely Access to Care Act passed the U.S. House with over 300 cosponsors but has yet to reach the floor of the Senate. Among other provisions, the bill would:

  • Establish an electronic prior-authorization process to streamline approvals and denials;
  • Create national standards for clinical documents to reduce administrative burdens;
  • Create a process for real-time decisions for certain items and services that are routinely approved;
  • Increase transparency to improve communication channels and utilization between Medicare Advantage plans, health care providers and patients;
  • Encourage MA plans to adopt policies that adhere to evidence-based guidelines.

The Centers for Medicare & Medicaid Services also is working on prior-authorization reform. Late last year, CMS proposed new rules that aligned with many of the key provisions of the congressional legislation. Marshall and other lawmakers are urging CMS to promptly finalize the proposed rule and expand its provisions.

Health Care Forum

MSSC is holding a health care forum with Sen. Roger Marshall, MD. Hear updates on issues such as prior authorization, drug costs, fentanyl and Medicare payment reform.

  • WHEN: 6:15-8 p.m., Tuesday, Aug. 22.
  • WHERE: Niche, 124 S. Broadway
  • COST: Free. Hors d’oeuvres and drinks provided. Spouses welcome.
  • RSVP: By Aug. 14. Call (316) 683-7558 or email