Close to 300 members of Congress are urging federal regulators to do more to reduce burdensome Medicare Advantage requirements that can slow delivery of care to nursing home and other patients.

The 61 senators and 233 Representatives signed a letter to the Centers for Medicare & Medicaid Services urging the agency to continue its recent efforts to “lessen administrative burden for providers.”

Chief among the proposals highlighted in the Wednesday request was a call for a real-time mechanism supporting quick electronic prior authorization (PA) decisions for routinely approved services.

“This mechanism would improve patient care and reduce provider burden while avoiding unnecessary delays,” reads the letter, which was spearheaded by Sens. John Thune (R-SD) and Sherrod Brown (D-OH). “Hundreds of organizations representing patients, physicians, hospitals and other healthcare experts have put their support behind an e-PA proposal that includes a real-time process for items and services that are routinely approved.”

In a 2024 Medicare and Medicare Advantage rule finalized in April, CMS began to initiate some changes to prior authorization requirements that have been broadly criticized by skilled nursing providers as blocking access to nursing home care that would be covered by traditional Medicare benefits. One long-time SNF payment expert told McKnight’s Long-Term Care News that nursing home stays and MRIs are the top two services denied by MA’s prior-authorization process.

The 2024 rule limits MA insurers to using prior authorizations only in cases when a diagnosis is unclear, which was expected to lead to easier transfers of hospital patients to nursing homes.

The lawmakers are asking CMS to adopt policies that further that effort and ensure immediate access to all kinds of care by:

  • creating a deadline of 24 hours for MA plans to respond to prior authorization requests for urgently needed care, and 
  • requiring detailed transparency metrics

Tackling dangerous practices

Thune, in a press release, noted that transparency efforts reflect elements of the Improving Seniors’ Timely Access to Care Act, which was backed by some 500 provider groups when it passed the House last year. Those included LeadingAge, the National Association for the Support of Long-Term Care (now ADVION), the American Geriatrics Society and other groups working with seniors.

The legislation has been reintroduced in both chambers of Congress this session. MA tactics have continued to draw the attention of Congress this year, with “impossible” denials and the use of artificial intelligence in decision-making about SNF stays decried at a May Senate hearing.

“Prior authorization remains an enormous burden on doctors’ practices and a threat to patient care, as insurers often provide no evidence of overutilization for targeted procedures and treatments,” the lawmakers wrote Wednesday. “Insurers continue to delay and even deny covering necessary care and overstep medical decision-making while increasing their profits.”

The fiscal 2024 rules went  into effect June 5.

The lawmakers also said that faster approvals would offer an incentive to providers, too.

“Based on industry growth (due to market demand), robust evidence continues to demonstrate that implementing real-time decisions produces cost savings for healthcare providers and health plans,” they noted.

Their letter also underscored that today’s prior-authorization process, which can take up to 72 hours under current regulation, could create life-or-death situations.

“We are concerned that delaying care for up to three days could jeopardize a patient’s life, health, or ability to regain maximum function,” the letter stated.