A House bill introduced April 20 by a bipartisan group of representatives, five of whom are also physicians, aims to tighten prior authorization timelines and impose stricter denial policies.
“Medicare is a promise to America’s seniors that they will have dependable access to quality healthcare in their later years. However, that promise has been undermined by unnecessary barriers to care — particularly through excessive use of prior authorization and inappropriate coverage denials in Medicare Advantage,” Rep. John Joyce, MD, R-Pa., the bill’s primary sponsor, said in an April 22 news release. “As a physician, I have seen firsthand how these delays harm patients and take valuable time away from the doctor-patient relationship.”
Most provisions would begin Jan. 1, 2028.
Here are five of the bill’s provisions:
1. Insurers would need to respond to standard prior authorizations within 72 hours and expedited requests in 24 hours. This tightens existing timelines from the CMS interoperability rule.
2. Some services would require real-time authorization decisions. Qualifying services would have at least 90% approval rates for MA organizations, and are low risk or have high administrative burden. Automated denials would need to inform providers of which documentation is needed.
3. The bill sets up a compliance scoring system, ranging from 0 to 100, for MA plans. Those with low scores could see up to a 2% automatic payment cut that would affect all of an insurer’s MA plans. The assessed categories would also contribute to star ratings more heavily than other domains.
4. The bill would ban third-party vendors that routinely automate denials in medical necessity reviews, as well as any arrangements that base payment on amounts of particular decision types.
5. Medical necessity criteria for MA cannot be more restrictive than that for traditional Medicare.
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