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Electronic Prior Authorization Bill Reintroduced in Congress

by Tara Cepull, MA | Sep 3, 2024 | Essential, Health care reform-nir, Lab Industry Advisor, Legislation-lca

For clinical labs, the proposed law could bring more consistency to test ordering

An older female patient discusses test results with her female doctor, who is holding a clipboard. — iStock, Lordn

US lawmakers have long thought that prior authorization (PA) for medical services has pitfalls, including its reliance on paper, collection of oftentimes unnecessary information that can lead to denials of treatment approval, and lack of transparency and oversight of related processes.

The American Medical Association (AMA) released statistics in 2023 from a physician survey that also illustrated unhappiness with PA. The AMA noted that 24 percent of providers reported a serious adverse event, such as hospitalization or a disability, for a patient under their care as a direct result of the wait times through the mandated PA process. The report estimated that providers spend approximately 12 hours every week completing PA paperwork, which more than 95 percent of these providers said somewhat or significantly increases burnout.¹

A bill aimed at addressing these issues that was previously sponsored by U.S. Representative Suzan DelBene, a Democrat from Washington state, has been reintroduced with bipartisan and bicameral support. The goal of the bill—called the Improving Seniors’ Timely Access to Care Act—is to decrease PA administrative burden for Medicare Advantage (MA) beneficiaries so that providers may focus more on patient care and outcomes.

Revised proposal seeks greater PA transparency

According to a press release on DelBene’s website, the proposed bill would:²

Establish an electronic PA process for MA plans, including guidelines for standardization.

Provide transparency about MA PA requirements and use.

Offer clarification on the U.S. Department of Health and Human Services’ (HHS) ability to implement acceptable time frames for electronic PA requests.

Expand beneficiary protections to improve health outcomes.

Require HHS and other agencies to report on the efficacy of PA programs and propose additional ways to improve the e-PA process.

Senator Roger Marshall, MD, a Republican from Kansas and one of the bill’s cosponsors, included a summary of the act in his own press release.³ His summary dives into particular detail on obtaining transparency for MA PA processes and how reports to Congress will help evaluate the program’s efficiency in order to inform future improvements.⁴

Bill may help labs gain PA consistency

Currently, given the lack of standardization across payer plans, there are oftentimes different procedures required to obtain reimbursement for similar medical services. For example, one plan might cover a particular treatment or service without PA, while another individual’s plan may demand PA for the same service.

This is also true for laboratory testing, which informs 70 percent of all medical decisions.⁵ Having a standard regarding whether PA is necessary will help MA beneficiaries obtain the lab testing they need in order to make important treatment choices. To complement standardization, creating transparency can also assist with better patient experiences in accessing needed testing, which should lead to better patient outcomes.

In the AMA survey, 94 percent of providers reported care delays due to PA, which led to 78 percent of these physicians seeing patients abandon treatment plans altogether at least some of the time. Further, 93 percent of these providers communicated that PA had a negative effect on patient outcomes.¹

Given these concerns with care delays and treatment abandonment, ensuring that the PA process is completed quickly is of the utmost importance. Marshall’s summary of the bill notes that HHS could choose windows such as 24 hours for reviews to be completed, emphasizing that quicker PA processing is desired.

Ongoing monitoring and review to continually improve processes for providers, labs, and beneficiaries alike is sought. Requiring reports by HHS and other involved agencies may help Congress create better healthcare policies and reforms moving forward. Many critics of PA point to the lack of current enforcement to ensure timely processing and efficacy of the PA process, and the update to this bill aims for Congress to take on this responsibility.

Final thoughts and tips for labs if the bill passes

The interpretation of passed legislation is what guides industry changes, and it is hard to determine at this time what the result might be for the proposed bill. Staying up to date on healthcare reform and following this bill’s progression through Congress is one way lab professionals can inform their operations and be ready to implement change, when necessary.

A laboratory healthcare attorney who wishes to remain nameless advises accepting that there are administrative hoops to navigate in order to obtain PA. Dedicating the required resources to constantly review, understand, and adapt to individual policies and plans is necessary, even if the bill does not pass. This is especially important because even minor changes to said policies can result in claim denials if the lab’s billing team is not aware of updates to the process or documentation that they are required to submit.

It is assumed that the proposed PA reform would potentially alleviate some administrative burden on laboratories and providers alike, leaving more time for sample processing and patient care, respectively. Knowing what laboratory tests require PA is a major step to ensuring reimbursement for testing services rendered.

Ann Lambrix, vice president of payers and revenues management at GoPath Diagnostics, suggests that labs have a good mechanism in place to obtain the information needed for PA.

Meanwhile, Liset Sanchez, client manager on the revenue cycle management team at Lighthouse Lab Services, comments that payers are requiring more documentation during the PA process to support clinical utility and that this information may not necessarily be readily available to the lab itself.

Lambrix adds that some labs rely on the treating provider for that information, while others work with a clinical team at the provider’s practice to complete the documentation necessary for PA. While we await the bill’s outcome in Congress, she encourages the establishment of timely and clear communications with payers to facilitate the submission of efficient PA requests without errors or missing information, which can result in denials that delay care for patients.