Congress tries again to crack down on prior authorization
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Congress is making another attempt at requiring Medicare insurers to speed up reviews of requests to cover treatments after an earlier effort was derailed by its high price tag.
Why it matters: A bipartisan bill taking aim at a practice detested by patients and doctors has a much better shot at passage after lawmakers made changes that will slash its cost to the federal government.
- The bill reintroduced Wednesday would codify recent reforms from the Biden administration cracking down on prior authorization.
- By doing so, it would help guard against the possibility of rollbacks by a future administration and an upcoming Supreme Court decision that could curtail federal rulemaking.
The big picture: Insurers often require patients to obtain preapproval for a procedure or medication to prevent costly, unnecessary care.
- But prior authorization is a major administrative headache for doctors, who cite it as a big driver of professional burnout and say it makes it harder for patients to get needed treatment.
- "Every doctor can tell you about patients that were delayed, which are frustrating and decrease their options or, even worse, decrease their probability of control and survival," said Catheryn Yashar, health policy chair of the American Society for Radiation Oncology.
Context: The bill would require Medicare Advantage plans to create electronic prior authorization systems that can streamline coverage decisions.
- The insurers would have to provide more reporting on their prior authorization decisions to the Department of Health and Human Services, which would also be given the power to set deadlines for insurers to respond to different types of prior authorization requests.
- The bill applies just to Medicare Advantage plans, while the Biden administration's recent prior authorization changes also apply to Medicaid and Affordable Care Act insurers.
State of play: The legislation has its best chance at being approved since it was first introduced five years ago.
- Nearly 400 health organizations back it, including Humana, the second-largest Medicare insurer.
- Notably, the bill shouldn't cost the federal government anything, said Peggy Tighe of the Regulatory Relief Coalition, a group leading efforts to pass the bill.
A previous version passed unanimously through the House of Representatives in 2022, but it stalled after congressional scorekeepers found it would cost $16 billion as fewer treatments would be denied.
- One big reason the last version cost so much was a requirement that insurers provide real-time prior authorization decisions on services and items that they frequently approve.
- The revamped bill instead asks regulators to report on how such a system could work.
Between the lines: The prospect that the Supreme Court could soon overturn a 40-year-old legal doctrine that gives agencies leeway to issue regulations adds urgency to the bill, advocates say.
- Pulling back the doctrine, known as Chevron deference, could make it easier for regulations to be challenged in court.
- In light of that possibility, it's "very important" to codify new prior authorization requirements for Medicare Advantage, Tighe said.
What we're watching: The bill could be rolled into a year-end legislative package, or it could be passed earlier through a simpler process reserved for noncontroversial legislation.
- "With the improvements we've made there is no reason we should not quickly get this bill signed into law," Sen. Roger Marshall (R-Kan.), a lead sponsor of the bill, said in a statement.
