“These tools are important when coordinating care, reducing unnecessary and low-value care, and promoting affordability for patients and consumers,” said spokesperson David Allen in a statement.ĬMS has a track record of responding to liberal concerns, which could translate into big changes for Medicare Advantage in the coming years. ![]() “We can’t do it because we can’t afford the constant chasing from all the denials,” he said.ĪHIP, the trade group representing insurers, told POLITICO that prior authorization was among the tools that can curb wasteful spending. James Lankford (R-Okla.) said some hospitals in his state won’t take Medicare Advantage plans any more. Those are among the incentives private insurers have to participate in the program and enrollment has doubled during the last decade.īut Sen. Unlike traditional Medicare, Medicare Advantage plans can employ prior authorization and restrict beneficiaries to certain doctors within their network. Jayapal was one of more than three dozen House Democrats who told CMS this month of “a concerning rise in prior authorizations,” accused health insurers of prioritizing “profits over people” and asked for “a robust method of enforcement to rein in this behavior.” Pramila Jayapal (D-Wash.), leader of the House Progressive Caucus. It “has turned into a process of basically just stopping people from getting care,” said Rep. Still, lawmakers are peppering the Biden administration with demands for reforming the commonly used tool called prior authorization, the process in which health insurers require patients to get insurer approval ahead of time for certain treatments or medications. The Improving Seniors’ Timely Access to Care Act, which mandates insurers quickly approve requests for routine care and respond within 24 hours to any urgent request, was reintroduced this year in the House and passed out of the House Ways and Means Committee this summer as part of a larger health care package. Legislation requiring insurers to more quickly approve requests for routine care passed unanimously in the House in 2022, but stalled in the Senate over cost concerns. ![]() He added that next year will likely bring “more scrutiny by the Hill and CMS on this, and there will be more reporting requirements for the plans and actions the plans are required to take to lessen the burden on providers and patients.” ![]() “CMS is very attuned to what is going on on the Hill,” Sean Creighton, managing director of policy for consulting firm Avalere Health, said of the Centers for Medicare and Medicaid Services. But its scrutiny of these care denials, which is expected to continue into next year, could have a far greater impact and reshape the rules for one of the most profitable parts of the insurance industry. Ron Wyden (D-Ore.) said in an interview, referring to a bevy of complaints from colleagues during a recent Senate Finance Committee hearing.Ĭongress has already gone after insurers for their celebrity-filled ads and misleading directories. “It was stunning how many times senators on both sides of the aisle kept linking constituent problems with denying authorizations for care,” Sen.
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