WHITEHOUSE REINTRODUCES BILL TO REFORM PRIOR AUTHORIZATION AND DELIVER CARE TO PATIENTS FASTER

The following information was released by Rhode Island Sen. Sheldon Whitehouse:

Legislation would help keep insurance companies from dictating care decisions to providers and patients

Washington, DC U.S. Senator Sheldon Whitehouse (D-RI) todayreintroduced the Prior Authorization Relief Act, legislation to cut the administrative burdens associated with prior authorizations a tool that requires health care providers to secure approval from health insurance plans before delivering medicines and services for a patient so that patients can get faster care. The bill eliminates prior authorizations from providers in value-based payment models.

"Americans are rightfully fed up with health care bureaucracy, and one of the many reasons is payment warfare by prior authorization,"said Whitehouse, a senior member of the Senate Finance Committee."Providers in value-based programs have every incentive to avoid unnecessary medical care, so these prior authorization requirements simply delay treatment and drive up overhead costs. My legislation aims to cut red tape and make it faster, easier, and cheaper to deliver high-quality care to patients."

Over 53 million prior authorization requests were submitted to Medicare Advantage health insurance plans in 2024. When used correctly, prior authorization can be an important tool to ensure that prescribed medicines or services are medically necessary and cost-effective. When used incorrectly, prior authorization leads to increased administrative red-tape for health care providers and potential harm for patients. In a 2024survey, 94 percent of practicing physicians, including primary care physicians, said that prior authorizations harm patients. Cancer patients facing the most challenging times of their lives have described how prior authorizations made them "so tired and drained at that point that [they] just went with the 'less effective' care suggested."

Senator Whitehouse'sPrior Authorization Relief Act would require the Centers for Medicare and Medicaid Services (CMS) to perform an audit across prior approvals required in Medicare Advantage insurance plans for medicines and services. The legislation also ensuresCMS standardizesprior authorization requirements across those medicines and services identified through the Agency's audit. Standardizing prior authorization protocols would allow patients to get care sooner and reduce providers' administrative time and costs associated with providing the most utilized and cost-effective treatments for their Medicare Advantage beneficiaries. The bill also exempts providers in two-sided risk value-based payment models from prior authorization for their Medicare Advantage patients.

"Prior authorization continues to be a significant barrier to care faced by Medicare Advantage enrollees, and additional oversight and accountability are desperately needed,"said David Lipschutz, Co-Director of the Center for Medicare Advocacy."Standardizing prior authorization requirements would be an important step forward towards achieving such accountability."

"As the nation's leading physician organizations providing accountable care, America's Physician Groups support the reintroduction of Senator Whitehouse's proposed reforms to prior authorization in Medicare Advantage,"said Susan Dentzer, CEO of America's Physician Groups."Recent evidence shows that there are growing volumes of waste in American health care, as well as provision of low-value care that can harm patients. Prior authorization is an essential tool for weeding out this wasteful and harmful care, and standardizing use of the tool across the Medicare Advantage program is desirable and appropriate for beneficiaries, providers, and plans alike. We also endorse use of gold card programs for high-value providers across Medicare Advantage plans, as well as within the Medicare Shared Savings Program, as the Senator's legislation proposes."