Prior Authorization

Prior authorization approval is required for a wide range of services and medications in traditional Medicare, Medicare Advantage (MA) and commercial plans. While intended to control costs, this process can delay or deny necessary medical care which negatively influences patient outcomes. A recent American Medical Association survey found that 34% of physicians reported a detrimental event for a patient due to prior authorization delays.

In April 2022, the Office of Inspector General for the U.S. Department of Health and Human Services released a report which found that MA plans inappropriately denied up to 85,000 prior authorization requests in 2019, and nearly 20% of reimbursement payments were denied despite meeting Medicare coverage rules. Reforms to the prior authorization process in MA plans is made even more timely as MA enrollment surges, with over half of Medicare beneficiaries expected to be enrolled in an MA plan by 2025.

The Centers for Medicare & Medicaid Services (CMS) released a final rule in January 2024 that requires certain payers, including MA plans, to streamline their prior authorization processes and improve the exchange of health information electronically. The rule requires eligible payers to respond to expedited prior authorization requests within 72 hours and seven days for standard requests. Following the publication of this rule, lawmakers on Capitol Hill have been pursuing various avenues to continue reform efforts.

In the 117th Congress, the Improving Seniors’ Timely Access to Care Act, which passed the U.S. House of Representatives unanimously, sought to directly improve flawed prior authorization processes within MA plans and garnered the support of 52 cosponsors in the U.S. Senate. While also requiring MA plans to establish means for electronic prior authorization processes, it would also help address concerns not fully resolved by CMS’ rule including real-time decisions for items and service that are routinely approved.

Additionally, the Getting Over Lengthy Delays in Care As Required by Doctors (GOLD CARD) Act (H.R. 4968) seeks to provide a federal equivalent to prior authorization that is modeled after state requirements in Texas and West Virginia.. This legislation exempts physicians, who in the previous year received approval for at least 90% of their prior authorization requests, from the prior authorization approval process for MA by issuing a “gold card." The Gold Card status could be revoked if a review found that less than 90% of claims approved would otherwise be denied​.