Illustration: Shoshana Gordon/Axios
Language addressing insurer prior authorizations in Medicare Advantage that was holding up completion of a year-end health care package is likely to be dropped by negotiators, per sources familiar with the talks.
Why it matters: Insurers' requirements for their sign-off on some physician-ordered care is a big tension point with patients and providers, and measures to streamline the system have been a focus of Congress and the Biden administration.
- But it appears likely that a prior authorization measure won't catch a ride on the CR because of lingering disagreements over several provisions, per sources.
- There is still a last-minute lobbying to include the bill in the package, and nothing is final until text is released, sources cautioned.
Inside the room: One sticking point is whether to codify a prior authorization rule the Biden administration issued this year or to include a prior authorization reform bill known as the Improving Seniors' Timely Access to Care in the package.
- Republicans have said they just want the rule, while Democrats want the actual bill.
Friction point: There's a slight difference in transparency requirements for insurers, and where information on prior authorization denials and related information would be posted.
- The bill says the MA plans would have to submit to CMS a list of all the applicable items and services subject to prior authorization, as well as the percentage of denials and appeals and other granular information.
- The rule states that the insurers have to publicly report certain prior authorization metrics annually on their websites.
- There was also conflict, as we reported last week, over new provisions being added to the bill which would have included a review system stemming from concerns about AI-generated denials, as well as $25 million for implementation.
What they're saying: Over the weekend, Democrats characterized Republicans' efforts as "watering down" the prior authorization requirements.
- A GOP aide said that Republicans were trying "to fix issues the Biden administration identified that would have undermined CMS authorities."
Context: The bill has had bipartisan and bicameral support, with majorities in both the House and Senate.
- The legislation had also been preliminarily scored to have no new cost and has the support of the Better Medicare Alliance, a Medicare Advantage advocacy group and a range of provider groups.
- But, notably, AHIP hasn't weighed in on the bill. Major MA plans Humana and CVS Health have given their endorsement.
