Congress reintroduces radiologist-supported bill aimed at curbing prior authorization
U.S. senators on Wednesday reintroduced bipartisan, radiologist-supported legislation aimed at curbing the use of prior authorization for imaging and other healthcare services.
Obstetrician and Sen. Roger “Doc” Marshall, MD, R-Kan., is leading the charge, joined by lawmakers from the other side of the aisle. They’re proposing the Improving Seniors’ Timely Access to Care Act, which would streamline how payers process healthcare utilization requests in Medicare Advantage.
The bill has support from 381 national and state organizations, among them, the American College of Radiology, Association of Academic Radiology, Society of Interventional Radiology and the American Society of Neuroradiology.
“Prior authorization is the number one administrative burden facing physicians today across all specialties, Sen. Marshall said in a statement. “As a physician, I understand the frustration this arbitrary process is causing healthcare practices across the country and the headaches it creates for our nurses. With the bipartisan, bicameral Improving Seniors’ Timely Access to Care Act, we will streamline prior authorization and help improve patient outcomes and access to quality care and life-saving medicine.”
The bill already unanimously passed in the U.S. House last Congress and was co-sponsored by a majority of members in both chambers, Marshall noted. Others introducing the new Senate version included Sens. Kyrsten Sinema, I-Ariz., John Thune, R-S.D., and Sherrod Brown, D-Ohio. Reps. Mike Kelly, R-Penn., Suzan DelBene, D-Wash., Larry Bucshon, MD, R-Ind., and Ami Bera, MD, Calif., are championing the new House version.
Prior authorization is a tool commonly used by health plans to reduce unnecessary care, forcing providers to obtain preapproval before they agree to pay for an MRI or other service. However, physicians and patients have accused the insurance industry of abusing prior authorization to help pad profits.
Providers have cited prior authorization as their No. 1 administrative burden, a recent study found. About 3 out of 4 Medicare Advantage enrollees are subject to unnecessary care delays stemming from such utilization management, Marshall and colleagues noted. A recent HHS investigation found that payers eventually approve 75% of requests that were originally denied, with delays and red tape leading to patient anxiety and provider burnout.
A recent analysis found that radiology faces one of the heaviest burdens from prior authorization in Medicare Advantage. About 91% of diagnostic radiology providers performed one or more prior authorization service per year, behind only radiation oncology (97%) and cardiology (93%). Medical societies representing the latter two specialties also are supporting the bill.
“ACR, along with 370 endorsing organizations, is pleased to see this legislation reintroduced and looks forward to working with policymakers to address prior authorization,” the college said in a June 12 news update.
The Improving Seniors’ Timely Access to Care Act would aim to simplify PA by establishing an electronic process, including standardization for transactions and clinical attachments. It also would increase transparency around the process in Medicare Advantage and clarify CMS’ authority to establish timeframes for electronic requests. This would include expedited determinations and real-time decisions for routinely approved services. Marshall and colleagues also are proposing to expand beneficiary protections to “improve enrollee experiences and outcomes.” And they’ll require HHS and other agencies to report to Congress on these “program integrity efforts” and ways to further improve the process.
While the legislation came close to the finish line last time, it ran into roadblocks in the Senate. Lawmakers at the time cited the “high cost of implementation” and grappled with “political hurdles,” ACR noted in its update. Implementing the bill would cost the feds an additional $5.5 billion between 2022 and 2027, the Congressional Budget Office estimated previously. That’s because MA plans would likely increase their bids to include the cost of these new services, CBO said at the time.
Advocates hope that recent regulatory changes related to prior authorization, along with updated legislative text, will eventually lead to the bill’s approval. The new bill includes a requirement for CMS to issue a report on implementing real-time decisions, an analysis on enrollee impact, and clarify the agency’s authority to modify timeframes for making PA determinations. It also has a reduced score from the CBO, experts noted.
“With the improvements we’ve made there is no reason we should not quickly get this bill signed into law,” Marshall said in the statement.
The Medical Group Management Association also praised the bill’s reintroduction on Wednesday, noting that its members have identified PA in Medicare Advantage as “substantially more burdensome” than Medicaid or other commercial plans.
“By requiring MA plans to publicly reveal what services are subject to prior authorization, how many are approved, and how long on average they take to approve—this legislation will drive plan accountability,” said Anders Gilberg, senior VP of government affairs for the association, which represents over 15,000 group medical practices in radiology and other specialties. “MGMA looks forward to working with Congress to advance policies that ensure that no health plan can stand in the way of life-saving healthcare simply to increase their bottom line.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.