Doctors in Congress Want to Force Medicare Advantage to Answer in 72 Hours

Medicare Advantage plans are designed to help seniors save money in retirement, but that care may be delayed while waiting on prior authorization approval. In April, members of Congress introduced bipartisan legislation designed to address that issue. The bill would give health plans a set amount of time to complete standard authorizations, speeding up care access.

Here's how the bill might reshape the Medicare Advantage industry and how, if passed, it might benefit seniors who depend on these insurance plans.

The introduction of the Medicare Advantage Improvement Act

Representative John Joyce introduced the bill in the House, and it's co-sponsored by physicians in Congress, including Representatives Kim Schrier, Greg Murphy, Mariannette Miller-Meeks, and Ami Bera.

"Medicare is a promise to America's seniors that they will have dependable access to quality healthcare in their later years," Joyce said in a statement. 

"However, that promise has been undermined by unnecessary barriers to care — particularly through excessive use of prior authorization and inappropriate coverage denials in Medicare Advantage. As a physician, I have seen firsthand how these delays harm patients and take valuable time away from the doctor-patient relationship."

The proposed standard authorization deadline

If passed, the bill would require health plans to process standard authorizations within 72 hours, hopefully speeding up the process and giving enrollees access to health care sooner. Prior authorization extensions of up to seven days would only be allowed in limited situations.

Additionally, the bill would require health plans to use automated approval systems that are integrated into electronic health records, reflecting updates in real-time. It would also prohibit health plans from requiring new authorizations for any modifications or extensions during treatment that are clinically necessary.

A call for increased transparency

The bill also presses for increased transparency from health plans. Under the bill, insurers would be required to publish data on prior authorizations, including information on how long it takes the health plan to make determinations on those authorizations.

The issue of delayed and high prior authorization denials

That transparency is particularly important given the findings of a report released in June by the Department of Health and Human Services' inspector general. The report revealed that UnitedHealthcare, CVS Health, and Humana had the highest Medicare Advantage prior authorization denial rates for services like long-term acute care and inpatient rehabilitation. In some instances, insurers denied more than 70% of prior authorization requests.

According to the American Health Care Association (AHCA) and National Center for Assisted Living (NCAL), those findings contributed to "a doubling of seniors leaving Medicare Advantage for traditional Medicare." 

The Office of the Inspector General recommended that the Centers for Medicare & Medicaid Services collect prior authorization data more regularly to continuously investigate the issue of prior authorization denials and the variation in denial rates among insurers.

The impact of prior authorization denials

Prior authorization denials may have significant impacts on Medicare Advantage enrollees. Unexpected denials may result in confusion and make it difficult for enrollees to get the care they need. Prolonged delays in approvals may create extra stress and uncertainty, making it impossible for them to get timely treatment.

The companion effort to the Medicare Advantage Improvement Act

Senators Roger Marshall and Sheldon Whitehouse introduced a Senate companion to the Medicare Advantage Improvement Act in April. Separately, Senator Marshall is also leading the Improving Seniors' Timely Access to Care Act with Senator Warner — a related but distinct prior-authorization reform bill.

The Improving Seniors' Timely Access to Care Act would move Medicare Advantage plans to an electronic prior authorization system, require standard requests to be decided within seven days, and require plans to publicly disclose prior authorization data. In July, it passed the House Ways & Means Committee with a unanimous vote of 42-0 and is now awaiting further action in the House.

Support for the Medicare Advantage Improvement Act

The Medicare Advantage Improvement Act has received widespread support from organizations including the AHCA/NCAL, the American Medical Rehabilitation Providers Association, and the Medical Group Management Association.

"This bill addresses many of the obstacles driven by insurer-led Medicare Advantage plans that were making it unnecessarily difficult for seniors and their families to navigate care options and receive coverage for medically necessary care," said Nisha Hammel, Vice President of Reimbursement Policy and Population Health at AHCA/NCAL. 

"Coverage decisions for Medicare Advantage beneficiaries must be driven by each patient's needs and clinical necessity, with appropriate oversight that ensures compliance and patient protections."

Bottom line

At this point, neither bill has been signed into law, so this is an important issue for Medicare Advantage enrollees to continue to watch. If you're waiting on a prior authorization, it may be helpful to be proactive. Contact your insurance provider after two or three days to make sure they have all of the information they need. 

If you haven't received an approval a few days later, call back to ask about the status. Medicare Advantage plans bundle together coverage with extra senior benefits like prescription drug coverage, so stay proactive and work with your doctor to obtain those prior authorizations to ensure you're able to take full advantage of your coverage.

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