The American Hospital Association has urged lawmakers to strengthen oversight of Medicare Advantage plans and streamline the prior authorization process, which it described as a major barrier to timely, medically necessary care for patients and a contributor to clinician burnout.
In a July 22 statement to the House Ways and Means Subcommittees on Health and Oversight, the AHA outlined specific reforms to address widespread issues with prior authorization denials and delays under Medicare Advantage, which now covers more than 32 million seniors.
Here are five key points from the AHA’s statement:
1. Make prior authorization more uniform and transparent. The AHA supports the Improving Seniors’ Timely Access to Care Act, bipartisan legislation that would establish an electronic standard for prior authorizations, set time limits for plan decisions, and require Medicare Advantage plans to publicly report data on denials and approvals — including the use of AI in decision-making.
2. Crack down on delays for post-acute care. Delays in authorization for post-acute care are slowing discharges from acute-care hospitals and limiting access to rehabilitation and skilled nursing services, the AHA said. From 2019 to 2024, the average length of stay before discharge to post-acute care grew by 11.3% for Medicare Advantage patients, compared to 5.2% for traditional Medicare patients, according to Strata Decision Technology data cited by the AHA.
3. Expand CMS audits and penalties. The AHA called for CMS to increase data-driven audits of plans with a history of inappropriate denials and delays. It also asked Congress to ensure CMS enforces penalties — such as civil monetary fines and program suspensions — for plans that violate federal rules or apply more restrictive coverage criteria than traditional Medicare.
4. Mandate provider network adequacy and payment parity. Medicare Advantage plans are not required to include all types of post-acute care providers — such as inpatient rehab and long-term acute care hospitals — in their networks. The AHA wants Congress to require inclusion of these providers and ensure critical access hospitals are paid on par with Medicare’s cost-based reimbursement model.
5. Add transparency to denial notices. The AHA is also pushing for legislation that would require Medicare Advantage denial notices to include the name and credentials of the reviewing clinician. Currently, plans often omit this information or provide only initials, limiting accountability and preventing providers and patients from understanding the rationale behind denials.
Click here to read the full AHA statement.
