Automating the Prior Authorization Process for Medicare Patients

Why It Matters

The process of prior authorization is how insurance programs – both public and private – determine whether to pay for requested medical services. While prior authorization may be a mechanism to control costs, it can delay or deny necessary care and cause real harm to patients.

• Bipartisan legislation: A popular legislative proposal called the “Improving Seniors’ Timely Access to Care Act” would automate the prior authorization process for Medicare patients and require health plans to communicate directly with EMR systems to make approvals and denials faster.
• Streamlined processes: The automated process would make it much more obvious what clinical documents are required before determining whether insurance will cover a procedure or treatment. In fact, permission would be granted immediately for routinely approved services in certain circumstances.
• Context: This proposal is not new, but the timing may be just right as Members of Congress return home to face voters who have healthcare issues on their minds. In 2020, a regulation was proposed that would have automated prior authorization, but it applied to only Medicaid and individual health plans, not Medicare. The bill was never finalized for technical reasons. Federal agencies continued to work on it, but the Office of Inspector General for HHS got the attention of Congress when it released a report concluding that Medicare Advantage plans denied nearly 20% of reimbursement payments. Since then, the Improving Seniors’ Timely Access to Care Act has been steadily working its way through the legislative process and may be attached to a package that will be voted on soon.

More than Medicare?

It is unclear whether the legislation will apply more broadly to public and private programs other than Medicare, but there is hope that needing permission for medical services is no longer painful for all patients, regardless of insurance program.

Julie Barnes JD is the Founder and Principal of Maverick Health Policy. A former policy analyst, healthcare attorney, and Capitol Hill staffer, Ms. Barnes has years of experience helping the private sector navigate federal government activities that influences medicine.