Medicare Advantage documents
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Providers demanding change to the Medicare Advantage program may soon get their wish after a House panel advanced a measure that would reform the program’s prior authorization process. 

The proposal, titled the Improving Seniors’ Timely Access to Care Act of 2022, aims to reform the prior authorization program under Medicare Advantage to ensure seniors get necessary care. The number of seniors enrolled in Medicare Advantage programs continues to swell each year.

The legislation would specifically establish an electronic prior authorization program, while also standardizing and streamlining the process for routinely approved services. MA plans would also be required to annually publish specified prior authorization information, including the percentage of requests approved and the average response time under the proposal. 

The measure was pushed forward by the House Ways and Means Committee and is currently in the House Committee on Energy and Commerce. 

The legislation comes after a federal watchdog report found that Medicare Advantage organizations often improperly denied or delayed services — even though the requests met Medicare coverage rules — in order to increase profits.

Post-acute facilities were among the healthcare services often involved in denials that nonetheless met Medicare coverage rules.

The investigation also found 13% of prior authorization requests that MA plans denied met Medicare coverage rules. In addition, it determined that 18% of payment requests that were denied met Medicare coverage and billing rules.

Provider groups have since called on the federal government to conduct an investigation into Medicare Advantage organizations over the improper denials.