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The Department of Health and Human Services (HHS) Office of Inspector General (OIG) released two reports on June 11 demonstrating the impact that prior authorization barriers to care have on patients under the Medicare Advantage program and showing the necessity of implementing common-sense bipartisan reforms to prior authorization processes. 

HHS OIG released its report “The Three Largest Medicare Advantage Organizations Denied Requests for Long-Term Acute Care and Inpatient Rehabilitation at Some of the Highest Rates” on June 11, finding that among the 19 Medicare Advantage Organizations (MAOs) in this review, the 3 largest MAOs by enrollment (CVS Health, Humana, and UnitedHealth Group) denied prior authorization requests for care in LTCHs and IRFs at higher rates than most of their peers. This report raises concerns that overly burdensome and restrictive prior authorization requirements are delaying or preventing patients from accessing medically necessary care. 

HHS OIG released another report on June 11, “Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials,” finding that prior authorization denials for care in the SNF setting were overturned 95% of the time when appealed under Medicare Advantage. 

These new reports both highlight the urgent necessity of implementing reforms to the prior authorization process. Your Academy has consistently prioritized advocating for common-sense reforms to prior authorization requirements under Medicare Advantage to ensure appropriate access to care for patients who rely on PM&R physicians for their care and remove burden from physicians. 

Your Academy is currently working to advance multiple pieces of bipartisan legislation that would implement long-overdue reforms to the prior authorization process:  

• The Improving Seniors’ Timely Access to Care Act (H.R. 3514/S. 1816), bipartisan legislation that would streamline prior authorization under the Medicare Advantage program for frequently approved services and increase transparency for the process. Enactment of this legislation would also codify into law regulatory actions taken by CMS over the past several years that have implemented improvements to the prior authorization process.  

• The Medicare Advantage Improvement Act (MAIA, H.R. 8375), bipartisan legislation that would implement commonsense enhancements to Medicare Advantage plans, increase transparency and accountability to the prior authorization process under the Medicare Advantage program while ensuring that it remains a reliable choice for patients. 

• The Reducing Medically Unnecessary Delays in Care Act (H.R. 2433), bipartisan legislation that would require all prior authorization decisions and adverse determinations under Medicare and Medicare Advantage to be made by a licensed physician who is board certified in the specialty relevant to the request. 

Please take two minutes today to participate in this important advocacy work and contact your federal representatives and urge Congress to pass long overdue reforms to the prior authorization process under the Medicare Advantage program.