Prior Authorization & “Improving Seniors’ Timely Access to Care Act”

Recently, the United States House of Representatives unanimously passed legislation by voice vote that would impact the future of prior authorization for Medicare Advantage (MA) plans.

The legislation, “Improving Seniors’ Timely Access to Care Act”, is poised to reach the United States Senate floor, later this year, and pass, given its bicameral, bipartisan support.

The activity surrounding this legislation comes on the heels of a U.S. Department of Health and Human Services report released from the Office of Inspector General (OIG) declaring that Medicare Advantage organizations have inappropriately denied prior authorization and payment requests for covered healthcare services. 

The House’s “Improving Seniors’ Timely Access to Care Act,” along with its Senate companion bill has amassed the support of more than 340 legislative co-sponsors. Not only would the legislation address the OIG’s recent report but would also establish requirements and standards relating to the prior authorization process under Medicare Advantage plans. The legislation: 

• Requires MA plans to implement electronic prior-authorization (ePA) programs that adhere to newly developed federal standards, as well as establish real-time decision-making processes for items and services that are identified as “routinely approved.”
  

• Mandates that MA plans issue accelerated prior authorization decisions for all other services covered under Medicare Part C, i.e., required to be covered by MA plans.

• Enhances transparency by requiring MA plans to report to the Centers for Medicare & Medicaid Services on the extent of their use of prior authorization and the rate of approvals and denials.

A recent American Medical Association survey found that 93% of physicians reported that prior authorization led to care delays at least some of the time for patients, and 82% of physicians reported that denials, or delayed approvals, led patients to abandon their recommended treatment plan. The legislation is intended to address these issues by improving the efficiency and transparency of MA plan prior authorization, and has garnered strong support from leading provider trade organizations, such as the American Hospital Association, American Medical Association, and others.

For many years, the push to fix prior authorization has centered on automating existing processes. Many health plans have implemented ePA systems; however, simply automating the prior authorization process fails to take advantage of an automated process to drive better patient experiences and outcomes. Since Medicare Advantage plans are committed to improving clinical outcomes and providing members with access to the most appropriate healthcare services, MA plans should leverage solutions that incorporate clinical intelligence to guide high-value care choices. Additionally, providers should have confidence that health plans are evaluating these requests, not for the sole purpose of saving money, but to ensure safe, necessary care for each patient.

For the process to function smoothly, rules should be fully transparent to providers, as specified in a consensus statement issued by six national advocacy associations and one of the key pillars of the “Improving Seniors’ Timely Access to Care Act.” An intelligent authorization platform can easily address and exceed the legislative requirements for greater PA automation, transparency, and authorization times by utilizing evidence-based clinical criteria that are clearly defined and referenceable for physicians. In addition, providers should be given meaningful support to help achieve the fastest and best outcomes for patients, which is possible with a solution that integrates AI and machine learning, paired with clinical intelligence.

Cohere’s collaborative UM platform is designed to transform in-house or fully-delegated programs through technology, clinical intelligence, and actionable analytics.  Cohere’s solutions leverage ePA as an opportunity to improve patient access, reduce provider burden and enable greater collaboration between health plans, providers, and patients. We are the only UM platform designed to support the entire patient journey, not just individual transactions.

Our platform delivers digital submission rates of up to 95%. The majority of cases are determined in real-time, returning immediate approvals that expedite patients’ access to care by 70%. By supporting ordering providers with data, as well as transparent, clinically driven “nudges,” the platform builds trust with network providers and reduces care variation, and incentivizes high-value care. With clinical guidance provided at the point of authorization, the platform has helped health plans reduce denial rates by 63% and increase quality outcome metrics by 11 – 43%, while simultaneously reducing medical expense by 15%+.

Health plans currently relying on manual or partially automated prior authorization processes will need to invest in technology to comply with the requirements and standards outlined in the “Improving Seniors’ Timely Access to Care Act.” The upcoming legislation provides an opportunity for health plans to abandon manual prior authorization processes and adopt technologies that not only support regulatory compliance but also enable new, strategic opportunities.

If you’re interested in learning more about how the “Improving Seniors’ Timely Access to Care Act,” will impact prior authorization for MA plans, connect with us today.