Handling the hassle of administrative hurdles

CMS released a proposed rule to address the administrative hassles of prior authorizations in Medicare Advantage plans, calling for automated processes, shorter decision-making time frames, and more transparency about the services subject to prior authorizations.

While I hate to see summer go by the wayside, I do have a real appreciation for fall and the month of November in particular. It is when my twin boys were born (now nearly 19 years ago) and when I get to cook some of my favorite foods, like butternut squash, pumpkin muffins, applesauce, and more. I also love that it is a time where we are all asked to focus on gratitude. One thing I am deeply grateful for is the care I have received from my physicians throughout the year, and my health overall. However, like most individuals, I do take some medications regularly—one of which is always a hassle when it comes time for my physician to renew it. Although this medication has been shown to work very well for me over the years and the alternative gives me migraines, I have had to go through several rounds of step therapy and then prior authorizations in order to keep taking it. This is simply absurd. Any sort of hassle like this that clearly questions the physician's judgment and does not allow for timely and appropriate patient care is one that must be questioned and likely eliminated.

ACP discussed this issue in a 2017 paper titled “Putting Patients First by Reducing Administrative Tasks in Health Care.” We noted that “tasks that are determined to have a negative effect on quality and patient care, unnecessarily question physician and other clinician judgment, or increase costs should be challenged, revised, or removed entirely.” Studies show the average cost for prior authorization approval in primary care practices ranged from $2,161 to $3,430 annually per full-time physician. Additionally, in a 2022 survey conducted by the American Medical Association (AMA), 86% of respondents reported that prior authorizations resulted in increased use of health care resources, leading to waste rather than the cost savings claimed by insurers. Approximately two-thirds of respondents reported that prior authorization requirements led to either diversion to ineffective initial treatments, like I experienced, or additional office visits.

Thankfully, this issue is on the minds of both the Biden administration and Congress. Early in 2023, CMS released a proposed rule to address the administrative hassles of prior authorizations in Medicare Advantage (MA) plans, calling for them to implement automated processes via a standardized interface; meet shorter decision-making time frames, including timely notifications to both patients and clinicians; and increase the transparency of the list of services subject to prior authorizations, metrics used to track approvals and denials, and the average times for prior authorization determinations. ACP submitted feedback to CMS on this proposed rule expressing our overall support while calling for improvements. We noted our disappointment that this rule only applies to certain payers when it should be expanded to include Medicare fee-for-service (Part B) and drugs (Part D). We also noted that payers' negative coverage decisions should be required to include precisely what documentation is needed from the clinician for a reversal. Finally, we called on CMS to shorten the proposed limits of 72 hours for responding to urgent requests and seven calendar days for nonurgent requests to 24 or 48 hours and five calendar days, respectively.

Even though CMS released this proposed rule early in 2023 and the comment period closed months ago, we are still awaiting the release of the final rule. It is unclear why it is being held up, and so we are pushing CMS to move forward. Even if the agency does not address all of our feedback in the final rule, it will be a significant step toward addressing administrative burdens for physicians and their patients.

Congress has also taken notice of this issue via legislation first introduced in 2019, titled the Improving Seniors' Timely Access to Care Act. ACP has repeatedly voiced support for this bill, with the latest version requiring that MA plans establish an electronic prior authorization process to streamline approvals and denials and that HHS establish a process for MA plans to provide “real-time decisions” for prior authorization requests of routinely approved items and services. Another related bill in Congress that ACP supports is the Safe Step Act, which would amend the Employee Retirement Income Security Act (ERISA) to require group health plans to provide an exception process for administering prescription drugs in their step therapy protocols.

Unfortunately, even though they are generally bipartisan in nature, both bills are getting caught up in the end-of-year battles over appropriations and other must-pass items. The Improving Seniors' Timely Access to Care bill also faces other hurdles. In September 2022, the Congressional Budget Office (CBO) provided a score of that bill, estimating that it would cost $16.2 billion over the course of 10 years. This was a surprise to many who supported the bill and the primary reason it did not move forward last year. The CBO has not released a score for the latest version of the bill; however, another challenge is the fact that CMS has not yet released its final rule on prior authorization in MA plans, as Congress would like to make adjustments to its bill to align it with and strengthen the final rule from CMS. The College plans to continue advocating for moving both the prior authorization and step therapy bills forward. You can help us by sending an email to your members of Congress calling on them to include these two bills in the end-of-year health care package.

ACP is also tracking prior authorization-related activity in the states. In 2023, at least 26 bills have been introduced in 16 states to reform prior authorization requirements for procedures, tests, treatment, and prescriptions. Many proposals for prior authorization reform contain one or a combination of the following types of provisions:

  • requirements for response time to requests (e.g., 24 hours for urgent, 48 hours for nonurgent);
  • mandates that prior authorization requirements be based on evidence, such as peer-reviewed clinical data;
  • requirements that denials be made by a physician of the same specialty;
  • allowance of continued validity of authorizations for medication dose changes or for ongoing management of chronic conditions;
  • requirements for insurers to publicly release data on prior authorizations by different medications or services; and
  • restriction of insurers from requiring other administrative burdens or related measures in addition to a prior authorization, such as step therapy protocols.

ACP chapter leaders can request that ACP National create a grassroots alert for chapter members to directly contact state officials regarding prior authorization or other critical issues by using our Advocacy Assistance Request Form. This form can also be used to seek out ACP National staff input on policy issues more broadly. Additionally, chapter leaders and members can access our new state health policy toolkit on prior authorization reform. This toolkit not only provides information on what is happening at both the federal and state level on prior authorization efforts but also offers members the opportunity to share with the ACP National staff information on your experiences with prior authorization and other administrative burdens, as well as any best practices for managing these hassles. These anecdotal stories are extremely valuable, as they allow us to better articulate to lawmakers and other policymakers what is actually happening on the ground.

In addition to the gratitude I have for my health and the health care I have received over the past year, I am deeply grateful to ACP members and my ability to advocate on your behalf. My hope is that you will take on the challenge of engaging more directly in our federal and state efforts to address prior authorization, other administrative burdens, and the countless additional issues that you and your patients face in your daily lives. There is never a better time than now to get involved!