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AUA among groups urging passage of prior authorization bill


Hassles caused by Medicare Advantage prior authorization requirements are being targeted by a coalition of medical specialty organizations and a bipartisan group of congressional representatives who are responding to their concerns.

Hassles caused by Medicare Advantage prior authorization requirements are being targeted by a coalition of medical specialty organizations and a bipartisan group of congressional representatives who are responding to their concerns.

The key culprits are Medicare Advantage plans that have imposed increasingly onerous prior authorization requirements for medical services that are adversely affecting patient access to necessary medical care, according to the Regulatory Relief Coalition (RRC).

The coalition, which includes the AUA and seven other national medical specialty groups, contends that prior authorization requirements are worsening, patients often experience long delays before obtaining needed treatment, and physicians’ offices are overburdened with the time-consuming process of obtaining the needed approval.

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“Prior authorizations are the worst,” said Robin Shaw, billing manager at Urological Associates of Savannah, PC, in Savannah, GA. “We are getting 100% of the CY Medicare fee schedule; however, the administrative burden is ridiculous. I have had to hire someone additional to do pre-certs due to the requirements they have placed on us for authorizations.”

“The preauthorization gauntlet prevents or delays patients from receiving needed diagnostic tests and therapies and adds significantly to health care provider costs and regulatory frustrations with the clear goal for enhancing profits for insurance companies,” Neal Shore, MD, of Atlantic Urology Clinics, Myrtle Beach, SC, told Urology Times. Dr. Shore is past president of LUGPA.

In a Policy and Advocacy Brief posted on its website, the AUA said the pre-cert process typically requires physicians or their staff to spend the equivalent of 2 or more days each week negotiating with insurance companies-time that would be better spent taking care of patients, especially since the vast majority of requests ultimately are approved.

Next: What proposed bill would doWhat proposed bill would do

According to the RRC, H.R. 3107, the bipartisan Improving Seniors’ Timely Access to Care Act of 2019, would protect patients from unreasonable Medicare Advantage plan requirements that needlessly delay or deny access to medically necessary care. It would require the Centers for Medicare & Medicaid Services (CMS) to regulate Medicare Advantage plans on prior authorization’s use. It would also require the plans to report to CMS on the extent of such use and the rate of approvals or denials by service and/or prescription medication.

The bill is sponsored by Reps. Suzan DelBene (D-WA), Ami Bera, MD (D-CA), Roger Marshall, MD (R-KS), and Mike Kelly (R-PA). It is based on a consensus statement adopted by leading national organizations representing physicians, hospitals, and health plans.

Last year, over 100 members of Congress called for such reform in a bipartisan letter to CMS.

According to Dr. Bera, the legislation would improve the prior authorization process in Medicare Advantage plans through improved transparency, electronic adoption, and an analysis on the items and services subject to prior authorization.

“Of all the much-needed updates to prior authorization, none is more critical than ensuring that, for routinely approved services, health plans make prior authorization available in ‘real time’ so that physicians and their staff have more time to spend on patient care, rather than paperwork,” Dr. Bera said.

In addition, the bill includes a surgical exception that allows the surgeon to rely on the initial authorization if he/she needs to perform additional services while the patient is in surgery.

“Physicians spend far too much time on burdensome paperwork and seeking authorization on certain items when they can be spending that time taking care of their patients. This bill modernizes the process and is a win for physicians and patients,” Dr. Bera said.

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“When seniors need critical medical care, doctors and support staff should be spending their time working with patients instead of having to haggle with insurance companies over whether they can do their jobs,” DelBene said. “This bipartisan legislation creates sensible rules for the road and will offer transparency and oversight to the prior authorization process.”


Survey outlines prior auth’s toll

In conjunction with introduction of the legislation, the RRC released results of a physician survey that details the extent to which abusive prior authorization policies are putting patients at risk and increasing burdens on physician practices.

According to the survey:

  • Eighty-two percent of respondents say prior authorization either always (37%) or often (45%) delays access to necessary care.

  • For most physicians (74%), it takes 2 to 14 days to obtain prior authorization, but for 15%, this process can take from 15 to more than 31 days.

  • Prior authorization causes patients to abandon treatment altogether, with 32% reporting that patients often abandon treatment and 50% reporting that patients sometimes abandon treatment.

  • Eight-four percent of physicians say the burden associated with prior authorization has significantly increased over the past 5 years.

  • The burden associated with prior authorization for physicians and their staff is high or extremely high (92%).

  • Despite gaining prior authorization, insurance companies deny payment after services are rendered, an outcome three-fifths of physicians have experienced more than once in the past year, and 16% have had this happen 20 or more times.

  • Nearly three-fifths (59%) of physicians have staff members working exclusively on prior authorization, with most staff spending 10-20 hours per week on prior authorization.
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