Prior Authorization Bill Expected in Congress This Summer

Two House Republicans and a Democrat working on a draft

https://www.medpagetoday.com/practicemanagement/reimbursement/79314

WASHINGTON — Bipartisan legislation to ease the burden of prior authorization is expected to be introduced in the House this summer, a Republican staffer said.

“We’ve been working with [Reps.] Mike Kelly (R-Pa.) and Suzan DelBene (D-Wash.) on prior authorization,” said Charlotte Pineda, healthcare advisor to Rep. Roger Marshall, MD (R-Kan.), an ob/gyn, during a conference on free-market healthcare here earlier this month.

“It’s important to work across the aisle because you can actually get stuff done,” she continued. “It’s one thing to introduce a bill and another thing entirely to introduce it with members of the committee on which the bill has jurisdiction. So the three members hopefully will be introducing that later this summer.” Kelly and DelBene are remembers of the House Ways & Means Committee, which would likely have jurisdiction over any prior authorization bill.

Naida did not say what the bill might contain, and she was unavailable for comment at press time. However, during the last Congress, Kelly introduced the Prior Authorization Process Improvement Act, which was referred to the Ways & Means committee but got no further. That bill required the Secretary of Health and Human Services to submit a report to Congress within a year “on the feasibility of Medicare Advantage organizations and providers and suppliers of services … using certain technologies to facilitate the administration of prior authorization requirements under Medicare Advantage (MA) plans offered by such organizations.”

The bill called for the secretary to consult with an advisory panel of MA organizations, providers and suppliers of services, beneficiary representatives, and technology vendors in preparing the report. Among other things, the report would include “recommendations on how to improve the administration of such requirements through the use of technology.”

While the three lawmakers work on that bill, other activities related to prior authorization are continuing. In March, the eHealth Initiative, a coalition of provider and healthcare industry organizations, issued a paper on “Considerations for Improving Prior Authorization in Healthcare.” The document included four central points:

• Transparency of payer policy and evidence-based clinical guidelines available at the point of care may, in many cases, reduce the need for prior authorization and minimize care delays.
• Reducing the overall volume of services and drugs requiring prior authorization could decrease administrative burdens and costs for all stakeholders.
• Payers, healthcare professionals, and vendors should use existing, industry-endorsed standards whenever possible and explore incorporating new electronic standards that have the capability to improve the prior authorization process.
• Payers and healthcare professionals should explore alternative payment models that promote bundled authorization for procedures, medications, and durable medical equipment that are associated with a particular episode of care.

Over at the Centers for Medicare & Medicaid Services (CMS), the agency is participating in two different workgroups for its Document Requirement Lookup Services Initiative, which is aimed at making it easier for Medicare fee-for-service providers to find out what documentation is required in order for Medicare to approve a particular service for coverage.

“One workgroup is a private sector initiative hosted by Health Level Seven International (HL7), the Da Vinci project,” the agency explained on the initiative’s webpage. “The second workgroup, convened by the Office of the National Coordinator for Health Information Technology (ONC), is the Payer + Provider (P2) Fast Healthcare Interoperability Resource (FHIR) Taskforce.” FHIR (pronounced “fire”) is a common programming interface that is used in many health information technology applications.

Through working with those two efforts, “CMS is helping define the requirements and architect the standards-based solutions,” the agency said. “In parallel, CMS is preparing to support pilots testing the information exchanges for Medicare fee-for-service programs and possibly coordinate pilots with volunteer participants to verify and test the new FHIR-based solutions.”

On the insurer side of the equation, America’s Health Insurance Plans (AHIP), a trade group here for health insurers, is coordinating a demonstration project to automate prior authorization. “We expect to launch the demonstrating project later in 2019 in a manner that is scalable and as integrated as possible with provider workflow,” an AHIP spokeswoman said in an email to MedPage Today. “We will engage an independent organization to evaluate the impact of automation and release a final report in early 2020.”

She noted that only about 15% of healthcare services require prior authorization, which she said was “an important, safe care tool adopted by health plans and government-sponsored health care programs to help ensure patients receive the best results, better outcomes and better efficiencies.”

Specifically, prior authorization “prevents the overuse [of care], misuse [of care], or unnecessary (or potentially harmful) care and offers consistency and value to the patient, when there could be a wide variation provider performance, cost of the drug, and/or utilization within a clinician’s practice,” the spokeswoman said. “[It also] ensures care is consistent with evidence-based practices.”

But there is still work to be done to improve the process, she said, adding that AHIP “supports legislation that is designed to streamline and standardize electronic prior authorization, improve transparency, and encourage best practices that improve care coordination and reduce provider burden.”

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