Illustration: Aïda Amer/Axios
Democrats pressing to streamline the prior authorization process in Medicare Advantage have made some last-minute changes that add cost to the plan and could complicate its chances of being rolled into a year-end health deal.
Why it matters: The idea of simplifying the insurer treatment approvals has wide bipartisan appeal and was supported by an array of health providers that said it would reduce administrative burdens.
- A preliminary CBO score also found it wouldn't add spending — removing a concern that had doomed a previous proposal in 2022.
Inside the room: Democrats first put prior authorization on the table Friday as they passed offers back and forth with Republicans on a prospective year-end health package, sources said.
- A House Democratic source said it remained in another Democratic counteroffer going into this week.
- So far, Republicans haven't agreed to add the plan to a package but are receiving pressure from bill supporters, per a lobbyist source close to the bill.
- And Sen. Roger Marshall, one of the lead sponsors, is also applying pressure, telling Axios on Monday night that "we hope it gets across the finish line" and "there's a chance for it."
- Members of the GOP Doctors Caucus are said to be making calls in support of the bill as well.
Friction point: But some last-minute additions that Senate Democrats are trying to add to the bill could complicate the outlook.
- One measure would require that denied claims be reviewed by a provider with the same or similar specialty. That's tied to Democrats' concerns about documented cases of insurers using artificial intelligence to deny prior authorization claims.
- Another measure adds a $25 million funding request to set up what CMS needs to do implement the bill.
- The additional measures prevented an earlier effort to get the bill hotlined in the Senate, said the House Democratic source.
Context: A previous version of the prior authorization reforms passed the House by voice vote in 2022 but then stalled in the Senate after the CBO said it would cost $16 billion.
- This year, the Biden administration issued a rule requiring health insurers to streamline information within existing electronic prior authorization systems, and to issue coverage decisions within specified times.
- Handling those changes administratively dropped the cost of legislation that was reintroduced this summer to zero, since it was seen largely as a way to codify the Biden rule.
- A majority of lawmakers in both chambers have signed on as sponsors on the bill, and it has wide support across provider groups and the Better Medicare Alliance, a Medicare Advantage advocacy group.
The bottom line: It seems the prior authorization bill could make it over the finish line if one or both of the new provisions are dropped, said the lobbyist source.
- But it still could be squeezed out in the late back-and-forth, especially if negotiators decide to pursue a narrow health deal and punt unresolved issues into next year.
